Functional outcome in handsewn versus stapled ileal pouch-anal anastomosis

Functional Outcome in Handsewn Versus Stapled Heal Pouch-Anal Anastomosis Giuseppe Gozzetti, MD. FACS, Gilberto Poggioli, MD, Floriano Marchetti, MD, Silvio Laureti, MD, Gian Luca Grazi, MD, Mario Mastrorilli, MD, Simonetta Selleri, MD, Luca Stocchi, MD, Massimo Di Simone, MD, Bologna, Italy

Eighty-eight o f 1 1 9 patients w h o l m d e r w e n t ileal p o u c h - a n a l a n a s t o m o s i s f o r u l c e r a t i v e colitis w e r e evaluated. F o r t y patients had a h a n d s e w n a u a s t o m o s i s (Hs) ~4th u m c o s e c t o m y , and 4 8 had a stapled mlastomosis (St). In e a c h patient, we e v a h m t e d o p e r a t i v e , m o r p h o l o ~ c , fimctional, and m a n o m e t r i c features. T h e results hi the Hs mul St g r o u p s were shlfilar when the anastomosis was witlfin 1 c m o f the d e n tate line. In particular, there was no correlation between die tylre o f mtastomosis mid the n m n b e r o f bowel m o v e m e n t s in a 2 4 - h o u r period, the p r e s e n c e o f the urge to defecate, mul die use o f mltidiarrheal drugs. L e a k a g e was significmldy iffgher hi die Hs g r o u p , even when die a n a s t o m o sis was less than 1 c m f r o m the dentate lhie. Pouchitis was m o r e f r e q u e n t hi the Hs g r o u p , aud, witlfiu tiffs g r o u p , a m o n g those ~qth a s h o r t disttmce b e t w e e n the a n a s t o m o s i s and die d e n tate lhie. N o c o r r e l a t i o n s w e r e fotmd b e t w e e n the presetlce o f c o l u n m a r epidlelium o r active colitis hi the m u c o s a below the a n a s t o m o s i s , the fimctional o u t c o m e s , mid the h i c i d e n c e o f pouclfftis. ile possibility of fashioning a stapled ileal pouch-anal

anastomosis (IPAA) ~ has notably modified the techT nique proposed by Parks and Nicholls 2 in 1978 and has considerably simplified the anastomosis technique by decreasing the duration of surgery and surgical complication rates. This is what accounts for the great worldwide success that the stapled IPAA technique has achieved. Nevertheless, many criticisms have been made against this technique, which has also been defined 3 as an "ileal pouch-distal rectum anastomosis" rather than a "'true" IPAA. Besides this controversy of terms, very little is known about the actual functional differences between the handsewn and the stapled anastomosis techniques. The aim of this study was to correlate the functional results and the surgical techniques. PATIENTS AND METHODS There were a total of 136 patients who underwent IPAA between 1985 and 1992.

From From I1 Clinica Chirurgica, University of BoLogna, Bologna. Italy. Requests for reprints should be addressed to Gilbeno Poggioli, MD, II Clinica Chirurgica, Policlinico S. Orsola, Via Massarenti 9, 40138 BoLogna.Italy. Manuscript submitted April 19, 1993. and accepted in revised form December 2. 1993

The procedure was pedormed for 119 patients with ulcerative colitis (UC) and 17 patients with familial adenomatous polyposis (FAP). In all the patients who underwent surgery for FAP, a handsewn anastomosis was fashioned. This group was excluded from the present study. Of the 119 patients who underwent an ileal anal-pouch procedure for UC, 68 were stapled and 51 handsewn. Overall, 6 patients had their pouch removed due to surgical complications; 4 of these patients were among the first 30 cases? In another 7 patients, the ileostomy has not been closed yet. In 8 patients, the follow-up was less than 6 months, whereas in 10 patients a complete followup evaluation was not available. All these patients were consequently excluded from the study. Thus, the present study consists of 88 patients: 40 with a handsewn anastomosis (Hs) with mucosectomy and 48 a stapled anastomosis (St). In these 88 patients, the interior purse string was placed from below, transanally. Both groups had protective ileostomies that were closed within a mean of 2.2 months later. These 88 patients are homogeneous in regard to sex (male/female ratio 2:1 in both groups) and age (mean in Hs group 28.5 years: St group 33.6 years). All had a minimum follow-up of 1 year (mean 3.1). Thirty-eight of 40 patients in the Hs group were operated on prior to those in the St group. Since 1989, in light of the good clinical results reported by British investigators, 5 we have performed mainly stapled IPAA in patients with UC. The operations were carried out by three staff surgeons (GG, GP, MM). The 88 selected patients were evaluated (Table I). In each patient, the distance from the anastomotic ring to the dentate line was measured in centimeters. In the area below the anastomosis, a minimum of two biopsy specimens was obtained. A histologic examination was performed in order to assess the presence of either columnar (CE) or squamous epithelium (SE), and to detect any evidence of active colitis (AC). In the evaluation of the functional outcome, the following factors were considered: the number of bowel movements in a 24-hour period and at night, the presence of leakage (seepage: occasional staining of underclothes to a diameter of less than 2.5 cm; and soiling: need for a pad day and night), 6 the capability of discriminating between feces and flati, the presence of the urge to defecate, the need for antidiarrheal drugs, and the presence of perianal inflammation. The occurrence of one or more episodes of pouchitis, diagnosed on the basis of clinical, endoscopic, and histologic features] was also assessed. Lastly, two quality-of-life parameters were considered: the patients' ability to return to work and the presence of any modifications in their sexual functioning.

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TABLE I Parameters Evaluated in the Study Distance of the anastomosis from the dentate line (cm) Histologic examination of the area below the anastomosis (from a minimum of two biopsy specimens) Columnar epithelium Squamous epithelium Active colitis Functional results Bowel movements/24 hr Nocturnal bowel movements Leakage Discrimination between feces and flati Urgency Need for antidiarrheal drugs Perianal skin inflammation Pouchitis Quality of life Ability to return to work Modifications of sexual activity Manometric values Resting tone Maximum voluntary contraction pressure Length of high pressure zone Recto-anal inhibitory reflex Sensory threshold Defecation threshold Capacity of the reservoir

100 [] Ilandsewn [] Stapled 66.7

~

6O ~--~-:-:~

653.~

i

Epithelium

Columnar Epithelium

Active

Colitis

Figure 1. Distribution of squamous epithelium, columnar epithelium, and active colitis in the mucosa below the anastomosis in the handsewn and stapled groups (P = not significant).

All of the patients underwent anorectal manometry with a perfusing catheter (Amdorfer Medical, Greendale, Wisconsin) (4 perfusing ports, 90 ° apart) and the stationto-station technique. Resting tone (RT), maximum voluntary contraction pressure, and the length of the high pressure zone (HPZ) were measured along with the presence of the recto-anal inhibitory reflex (RAIR), sensory and defecation thresholds, and the capacity of the reservoir.

Statistical Analysis Results are espressed as a mean +_ standard deviation. All parameters evaluated were cross-tabulated with the type of anastomosis; differences were evaluated by means of the chi-square test (Yates' correction was used when appropriate). A P value <0.05 was considered as statistically significant.

,$26

RESULTS

Distance of Anastomosis from Dentate Line The overall mean distance of the anastomosis from the dentate line was 0.7 cm _+0.7 (Hs group 0.2 +_0.3 cm; St group 1.2 _+ 0.7 cm) (P <0.06).

Histologic Examination The histoiogic examination of the tissue below the anastomosis revealed no statistically significant differences in the distribution of SE or CE, or in the presence of AC (Figure 1). In particular, AC was found in 5.9% of the Hs group and 9.3% of those in the St group.

Manometric Values The manometric assessment evaluation provided data that were very similar in both groups. The results are listed in Table II. The only data that were significant were that of the RT (Hs group 42.9 mm Hg [_+ 19.1]; St group 52.2 mm Hg [_+ 18.5]; P <0.05).

Quality-of-Life Parameters

%

Squamous

The type of anastomosis, the distance of the anastomosis from the dentate line, the histologic findings, and the RT were cross-tabulated with functional outcome parameters, such as the number of bowel movements in a 24hour period, the presence of leakage, the capability of discriminating between feces and flati, and the occurrence of pouchitis. Eventually, independent influences of the aforementioned operative, morphologic, and manometric data on the functional outcome were evaluated by means of the stepwise logistic regression (SLR).

Sexual activity was unmodified in 76.6% of the patients, improved in 9.1%, and worsened in 14.3% (Figure 2). No difference was found in the 2 groups of patients. A total of 85.3% of the patients returned to work versus 14.7% who did not. Of these, only 6.8% were unable to return to work due to pouch-related problems (Hs group 42.9%; St group 57.1%; P not significant).

Functional Results Functional results are listed in Table llI. The only statistically significant difference concerns the degree of leakage: a higher incidence of leakage was found in the Hs group (Hs group 77.5%; St group 43.8%, P = 0.001) (Figure 3). When the leakage was correlated with the distance of the anastomosis from the dentate line independent of the type of anastomosis, there was a higher leakage incidence for a distance of less than l cm (P <0.05). Finally, a resting pressure of less than 30 mm Hg resulted in more frequent leakage (P <0.05). Upon SLR correlating the leakage with type of anastomosis, distance of the anastomosis from the dentate line, histologic pattern below the anastomosis, and RT, the incidence of leakage was correlated only to the RT (P <0.05) and showed a higher incidence of leakage when the mean resting pressure was less than 30 mm Hg. Likewise, when the cut-off was considered at 40 mm Hg, there was no statistically significant difference. The number of bowel movements did not show any correlation with the considered parameters.

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TABLE II Anomanometric Values Handsewn Group 2.3 178.6 64.5 138.5 3.3 271.4 42.9

High pressure zone (cm) Maximum voluntary contraction pressure (mm Hg) Sensory threshold (mL) Evacuation threshold (mL) Presence of recto-anal inhibitory reflex (%) Capacity of the reservoir (mL) Resting tone {mm Hg)

(± (± (± (±

Stapled Group

1.1) 35.9) 53.2) 99.2)

2.4 (± 174.9 (± 63.1 (± 136.9 (± 4.7 275 (± 52.2 (±

(± 99.7) (± 19.1)

1.1) 37.1) 41.5) 72.7) 99.5) 18.5)"

"P <0.05.

I00

I00

x\\\',:',:\ ",~ ~\\

%

\\~

." ~ . \ \ \ \ :

[ ] Leakage

[ ] No Leakage

77.5

76.6

)

%

\

14.3

o Unmodified

Im proved

Handscwn

Worsened

Figure 2. Sexual activity after ileoanal anastomosis.

Stapled

Figure 3. Degree of leakage in the handsewn and stapled groups (P = 0.001).

The capability of discriminating between feces and flati showed only a slightly nonsignificant correlation (P = 0.06) when cross-tabulated with the type of anastomosis. Nevertheless, upon SLR, when the capability of discriminating was evaluated together with the type of anastomosis, the distance of the anastomosis from dentate line, and the RT, the correlation was highly significant, showing that a higher percentage of patients with stapled anastomosis could not discriminate accurately (P <0.05).

Pouchitis One or more episodes of pouchitis were found in 11.6% of the patients. Of the patients with pouchitis, 76.5% were in the Hs group and 23.5% in the St group (P = 0.009) (Figure 4). Furthermore, the incidence of pouchitis showed a statistically significant correlation with the distance of the anastomosis from the dentate line (higher frequency of pouchitis in those anastomoses placed less than 0.5 cm from the pectinate line, regardless of the type of anastomosis) (P <0.05) (Figure 5). Using SLR, the incidence of pouchitis was then cross-tabulated with the type of anastomosis, the distance of the anastomosis from Ihe dentate line, and the presence of either CE or AC in the area below the anastomosis. The only statistically significant correlation was found between the incidence of pouchitis and the type of anastomosis (P = 0.001 ). COMMENTS Although this study is retrospective, it has clearly shown some particularly important differences. One of the most argued problems is highlighted by the occurrence of mi-

TABLE III Functional Results Handsewn Group Bowel movements/24 hr Nocturnal bowel movements Need for antidiarrheal drugs Urgency Discrimination between feces and flati Leakage Perianal dermatitis

4.9 (± 1.1) 0.7 (± 0.1) 15.0% 5.0% 80.0% 77.5% 30.8%

Stapled Group 5.0 (± 1.1) 1.0 (± 0.2) 4.2% 0.0% 61.7% 43.8%* 22.9%

"P = 0.001.

nor incontinent episodes. The leakage in our patients was more frequent in those who had undergone a handsewn rather than stapled IPAA. In a retrospective study, even Sugerman et al 8 found a higher incidence of leakage, both diurnal (daytime spotting 55% Hs versus 17% St) and nocturnal (nighttirne spotting 61% Hs versus 28% St) in patients with a handsewn anastomosis. Furthermore, in our experience, among the patients with a stapled anastomosis, leakage was more frequent in those in whom the anastomosis was placed closer to the dentate line. This seems to be especially related to intraoperative damage to the internal anal sphincter, and it has already been hypothesized '~ that it is provoked by two mechanisms. The first one entails the direct injury to the sphincter during the mucosectomy. The high incidence of nomaal continence in some studies m after a handsewn anastomosis

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100

[ ] Handsewn

[ ] Stapled

76.5 62

.'x\\\\\\\\'-~

%

~ \ \ \ \ \ \ \ \ \ \

23.5

~\\\\xx\xx~ ~x\\\\x\xx~ ~\\\xxx\\\~

0

!

Pouchitis

i

No Pouehitis

Figure 4. Pouchitis in the handsewn and stapled groups (P = 0.009). ioo

100

/

/

[ ] Pouchitm [ ] No Pouchitis 68.2

%

< C).5cm

> 0.5 cm

Figure 5. Pouchitis in those anastomoses placed less or more than 0.5 cm from the dentate line.

suggests that instead of the mucosectorny itself, the duration of anal retraction required to perlbml the mucosectomy is responsible for the sphincter impairment and thus the second potential mechanism. This last mechanism is confirmed by the experience of Tuckson et al ~ who, in a study of 153 patients, observed a lower incidence of seepage (6% versus 16%,) in those patients with a stapled anastomosis and purse string can'ied out from the abdomen. They referred to this group as the "'nonmanipulated group" versus the patients with a handsewn anastomosis and those with a stapled anastomosis and purse string carried out transanally who were the "manipulated group." Major leakage is also worse (12% versus 2%,) in the manipulated group. As mentioned previously, there are few prospective studies comparing the functional outcome of the two techniques. The only recent studies available come from SeowChoen et al ~-' and Luukkonen/3 As to the leakage, they provided contrasting results. Seow-Choen and colleagues reported mucus leakage in 3 of 15 handsewn cases and 2 of 17 cases of stapled anastomoses. Lukkonen's conclusions are at variance with those of Seow-Choen et al. After a short follow-up period of 6 months, of 40 patients (19 Hs and 21 St), 5 in the St group complained of leakage versus only 2 in the Hs group. Furthermore, 4 patients in the St group reported the need to wear a pad, whereas in the Hs group no case was reported. These differences are diMcult to account for. Likewise, it is quite problematic to explain why there are so many different results in the the rate of leakage in each of the 328

series. Perhaps it all depends upon the several, and sometimes controversial, definitions of leakage. In our series, we report a higher rate of leakage compared with other studies (77.5% in Hs and 43.8% in St), probably in part because, in its definition, we considered leakage to be any degree of leakage, including minor seepage and the need t'or wearing a pad, even when its use is due to merely psychologic reasons (patients who are afraid of leaking). One further consideration can be made in regard to the type of subanastomotic epithelium. In our study, we assessed the presence of either SE, CE, or AC below the anastomotic ring. The most surprising finding was the near-equal distribution of the different types of epithelium in the two groups of patients. In particular, although the mean distance of the anastomosis fi'om the dentate line was rather different in the two groups (0.2 + 0.3 cm and 1.2 + 0.7 cm in the Hs and in the St groups, respectively), the fi'equency of either CE or even AC was unexpectedly high in the Hs group (5.9% of AC in Hs group versus 9.3% in St group). King and colleagues H reported that 3 of 16 patients who underwent handsewn IPAA were found to have CE lined clown to the dentate line: moreover, the authors found in 10 cases clear signs of AC, in 4 cases a moderate dysplasia, and in 1 case a poorly differentiated adenocarcinoma. Sugerman et al ~ noted microscopically residual UC in 19 of 20 patients with stapled IPAA, but only 3 patients developed symptoms attributable to acute imflammation in diseased anal canal. Ova the other hand, Tuckson et al ~t did not find any rectal mucosa in the patients with stapled IPAA in whom a biopsy specimen of the anal transitional zone was obtained (we do not know the rate of available specimen). Furthennore, in our experience, the presence of CE and/or AC does not affect the functional outcome and thus suggests that islets of CE can be missed during the mucosectomy, but this finding "'has been shown not to be clinically relevant. ''15 The third relevant aspect of our study has been the incidence of pouchitis. In our experience, we have found a significantly higher incidence of pouchitis in those patients undergoing IPAA with the anastomotic ring located closer to the dentate line: among these, the highest incidence was found in the handsewn anastomosis group. Otherwise, no further risk of pouchitis was lbund even when AC was shown in the subanastomotic area. The type of the anastomosis (Hs or St) was identified as the most important factor in the multivariate analysis that simultaneously correlated the incidence of pouchitis with the type of anastomosis, the distance of the anastomosis fiom the dentate line, and the type of subanastomotic epithelium (CE, SE, or AC). We are not certain of the significance of this incidence of pouchitis. There is no evidence that the type of suture material used (either staples or absorbable sutures) can cause a different reaction in the reservoir. The only difference found in the two types of anastomosis is in the technique used to lengthen the ileum. In fact, in the handsewn IPAA, it is almost always necessary (at least with a J pouch) to section one or more mesenteric vascular arches and/or the ileocolic artery in order for the reservoir to reach the anus with-

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out tension. This procedure is rarely necessary when perfot'mirLg a stapled IPAA. Otherwise, in patients with FAP, the pouch-anal anastomosis has been handsewn and pouchitis is rare.

CONCLUSIONS IPAA is well accepted worldwide lbr the treatrnent of UC and FAP. Its success has increased even further since the introduction of the stapled techr|ique, which has shortened the duration of the operation and reduced the cornplication rates. The real difference in functional results among the patients who underwent the HS technique and those who underwent the St technique is not well-known, yet. The srnall arnour|t of data available it! the literature provides divergent results. This study showed no conspictlOUS differences between the two techniques. The average number of bowel rnovements was lbund to be similar as was the ability of the patient to corrffortably delay defecation, Undoubtedly, the patients with a stapled anastomosis showed a lower incidence of incontinence, which we believe is due to the better preservation of sphincter mechanisrns, especially the internal sphincter. This study also proved that sit-ice the incider|ce of CE and AC in the rnucosa below the anastomosis was sirnilar in both groups, it is not accurate to regard only the handsewn anastornosis as the "true" ileoanal anastomosis even though the distance of the anastomosis fi'orn the dentate line was quite different in the two groups. The presence of CE or AC did not affect the functional outcome nor the incidence of pouchitis, whicll was significantly higher among the patients with a handsewn anastomosis. This finding still needs to be confirmed by other studies, and, most of all, a convincing pathogenic explaination is necessary.

The.fitscinalion r!/'sttrgeons with the technical a.spec'ts q[" their patients' care makes this a "'must-read" ; in fact, the attthors s h o w once again that t/tere are.few d(ff'eren('es heIween ~l well-s~'wtt utttlSlOmosis arid d well-stapled otte.

REFERENCES I. Heald A J, Allen DR. Stapled ileoanal anastomosis: a technique to avoid rnucosal proctectomy in the ileal pouch operation. Br .I Surg. 1986:75:571-572. 2. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. BM.I. 1978:2:85-88. 3. Kelly KA. Anal sphincter-saving operations for chronic ulcerative colitis. Am .I Sm'g. 1992:163:5-11. 4. Poggioli G. Marchetti F. Scllcri S. et al. Redo pouches: salvaging or failed ileal pouch-anal anastomoses. Dis Cohm Rectum. 1993;36: 492-496. 5, Williams NS. Marzouk DEMM, Hallan RI, Waldron DJ. Function alter ileal pouch and stapled pouch-anal anastomosis lbr ulcerative colitis. Br .I Sm:e. 1989:76:1168-117 I. 6. Taylor AT, Wolff BG, Dozois RR, et al. Ileal pouch-anal anastomosis for chronic ulcerative colitis and familial polyposis colt complicated by adcnocarcinoma. Dis Cohm Rectum. 1988:31:358-362. 7. Di Febo G, Miglioli M, Lauri A. et al. Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis. Gastrointest Emh,sc. 1990:36:6-9. 8. Sugennan H J, Newsome HH, Decosta G, et al. Stapled ileoanal anastomosis Ibr ulcerative colitis and familial polyposis without a temporary diverting ileoslomy. Arm Sur.q. 1991 ;213:606-619. 9. Johnston D, Holdsworlh PJ, Nasmylh DG, et al. Preservation of the entire anal canal in conservative proctocolectorny for ulcerative colitis: a pilot .study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis. Br ./Surg. 1987:74:9411-944. 10. Dozoi~ RR, Goldberg SM, Rolhenbcrger DA, et al. Symposium: restorative proctocolectomy with ileal reservoir. Int J Colorectal Dis. 1986:1:2-19. 1 I. Tuckson W. Laver3, 1, Fazio WV. et al. Manometric and functional comparison of ileal pouch anal anastomosis with and withoul anal manipulation. Am .I Stlr,ll. [ 991 : 161:90-96. 12. Seow-Choen, Tsunoda A. Nicholls RJ, Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectorny. Br ,I Surg. 1991:78: 430-434. 13. Luukkonen P. Stapled vs hand-sutured ileoanal anastomosis in restorative proctocolectomy. A prospective, randomized study. Arch Sttr~.. 1993:128:437-440. 14. King DW, Lubowski DZ. Cook TA. Anal canal mucosa in restorative proctocolectomy for ulcerative colitis. BrJ Sto,tl. 1989"76: 97(1-972. 15. O'Connell PR, Pemberton JH. Wetland LH, et al. Does rectal mucosa regenerate after ileoanal anastomosis? Dis Colon Rectttm. 1987:30: 1-5.

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