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Pouch failures after ileoanal pouch anastomosis
A26
Abstracts
Abdominal tion and/or
recta-vagina-pexy faecal incontinence.
Italiaander, Surgery,
(RVP)
for
/Netherlands obstructed
Journal defaeca-
R. Silvis, A. van Essen, M.V. H.G. Gooszen, L.W.M. Janssen. Department of
Univer&
Hospital,
Utrecht,
Netherlands.
Aware of the moderate results of abdominal rectopexy for obstructed defaecation and the well-known risk of postoperative induction of constipation, we prospectively evaluated the results of a new type of rectopexy (RVP) for patients with obstructed defaecation (OD) and/or faecal incontinence (FI). From September 1991 to December 1993 a consecutive series of 39 patients (mean age 56 years, range 32-81 years) underwent a RVP based on complaints and abnormalities on dynamic defaecograms. 29 patients returned pre- and postoperative questionnaires and were analysed with respect to symptoms, pre- and postoperative dynamic defaecograms and anorectal physiological measurements. Indications for operation were often multiple: 26 patients were operated for OD and/or FI of whom 10 had abdominal pain as well and one had a concomitant rectal prolapse. Two patients had abdominal pain as single complaint and 1 patient only a rectal prolapse. Abdominal pain was not induced by, and was significantly reduced after, RVP (p = 0.004). Symptoms belonging to the obstructed defaecation syndrome were influenced to a variable extent: urge to defaecate without rectal emptying and a sensation of incomplete rectal emptying were unchanged; the need to support the anterior rectal wall was improved and the need for digital evacuation of faeces and excessive straining improved significantly (p = 0.04 and p = 0.0015, respectively). According to the definition of Drossman, patients with OD appeared to be constipated not because of a defaecation frequency of < 3 times a week but because of excessive straining. Constipation improved significantly after, and constipation was not induced by, RVP. Faecal incontinence scored according to Browning and Parks decreased significantly (p = 0.0007). RVP restored anatomy: all (13) enterocoeles, all (25) but 1 internal intussusception, and 20 of 32 rectocoeles dissolved while remaining rectocoeles were reduced in size. Decrease in grades of incontinence was correlated to decrease in grade of intussusception and decrease in constipation was correlated to decrease in grade of rectocoeles although not significantly (r = 0.59, p = 0.09 and r = 0.41, p = 0.11, respectively). Maximal anal resting pressure was unchanged while squeeze pressure decreased (p = 0.02). Rectal sensibility to distension was unchanged and rectal electrosensibility improved (p = 0.04). Conclusion: RVP reduces obstructed defaecation (OD) and faecal incontinence (FI) if patients are selected for operation based on symptoms and anatomic abnormalities on defaecograms. Postoperative constipation was not induced.
of Medicine
47 (1995)
AI -A42
colitis. Nevertheless, there remains the possibility of failure. We reviewed the results of our hand-sutured IAPA(HS-IAPA) to look for patterns of failure in an attempt to improve results. Between 1984 and 1990 76 patients received a HS-IAPA with deviating ileostomy. Forty-five were male and 31 female. Ages varied from 11 to 61 years (mean 33 years). Twenty-three patients had familial polyposis coli (FPC), 52 ulcerative colitis (UC) and 1 had Crohn’s disease. Twenty-two patients had their pouch removed. Eleven were male. Ages varied from 18 to 61 years (mean 34). Twenty-one patients had UC and 1 had FPC. Nine patients had preoperative prednisone average daily dosage 20 mg. In 16 patients the ileostomy was closed after 150 days on average. Twelve patients had leakage of the ileo-anal anastomosis, 8 before and 4 after the ileostomy was closed. Seven of the 16 patients who had closure of their ileostomy had faecal continence disorders: 2 soiling, 1 insufficiency and 4 total incontinence. Pouchitis occurred in 12 patients. Three patients developed a peri-anal fistula, 5 a pouch-vaginal fistula. Defaecation frequency during the day varied from 4 to 15 (mean 9) and at night from 2 to 5 (mean 3). In the group of 54 patients who still have a pouch its function is acceptable. Average defaecation frequency during the day is 6 and at night 1. Thirteen patients in this group have continence disorders: 8 soiling, 1 insufficiency and 4 incontinence, which is conservatively treated. Seven patients had their pouch removed because of leakage of the anastomosis and accompanying pelvic sepsis. Five patients all operated for UC had their pouch removed due to uncontrollable pouchitis. In 6 patients the pouch was removed because of faecal incontinence. Four patients experienced a pouch failure due to a pouch-vaginal fistula. The mean interval between pouch construction and failure was 2.5 years (6 days-8 years). The rate of pouch failure was highest in the first postoperative year. Pelvic sepsis, enhanced by previous colectomy and preoperative usage of prednisone, was the cause of early failure (before ileostomy closure). Pouchitis, incontinence and fistulas were causes of late failure (after ileostomy closure). In this study 76 patients had a HS-IAPA with diverting ileostomy. Cause of early pouch failure was pelvic sepsis, influenced by previous colectomy and preoperative use of prednisone. Causes of late pouch failure were incontinence, pouchitis and fistulas. Between 1990 and 1993, 66 patients received a double-stapled ileoanal pouch anastomosis. In the double-stapled group no pouch was lost. The influence of colooic involvement recurrence after ikocolonic resection
on postoperative surgical for Crohn’s disease. E.
de Jong ‘, J.F.M. Slors ‘, G.N.J. Tijtgat ‘, D.J. Gouma ‘. ikoanal pouch anastomosis. W.F. van Tets i, J.H.C. Kuypers ‘. Department of Surgery, I Bosch Medical Centre, Den Bosch, 2 University Hospital, Nijmegen, Netherlands. Pouch
failures
after
Since its introduction in the early 1980s the ileoanal pouch anastomosis (IAPA) is most acceptable to the patient and surgeon in the treatment of polyposis coli and ulcerative
Department of I Surgery Medical Centre, Amsterdam,
and 2 Gastroenterology, Netherlands.
Academic
Follow-up after ileocolonic resection for Crohn’s disease is characterised by a high incidence of recurrence at the anastomotic site and subsequent reoperative surgery. It is still not known which factors contribute to this high incidence of recurrence, but in the literature it is suggested that concomi-
Abstracts
Abdominal tion and/or
recta-vagina-pexy faecal incontinence.
Italiaander, Surgery,
(RVP)
for
/Netherlands obstructed
Journal defaeca-
R. Silvis, A. van Essen, M.V. H.G. Gooszen, L.W.M. Janssen. Department of
Univer&
Hospital,
Utrecht,
Netherlands.
Aware of the moderate results of abdominal rectopexy for obstructed defaecation and the well-known risk of postoperative induction of constipation, we prospectively evaluated the results of a new type of rectopexy (RVP) for patients with obstructed defaecation (OD) and/or faecal incontinence (FI). From September 1991 to December 1993 a consecutive series of 39 patients (mean age 56 years, range 32-81 years) underwent a RVP based on complaints and abnormalities on dynamic defaecograms. 29 patients returned pre- and postoperative questionnaires and were analysed with respect to symptoms, pre- and postoperative dynamic defaecograms and anorectal physiological measurements. Indications for operation were often multiple: 26 patients were operated for OD and/or FI of whom 10 had abdominal pain as well and one had a concomitant rectal prolapse. Two patients had abdominal pain as single complaint and 1 patient only a rectal prolapse. Abdominal pain was not induced by, and was significantly reduced after, RVP (p = 0.004). Symptoms belonging to the obstructed defaecation syndrome were influenced to a variable extent: urge to defaecate without rectal emptying and a sensation of incomplete rectal emptying were unchanged; the need to support the anterior rectal wall was improved and the need for digital evacuation of faeces and excessive straining improved significantly (p = 0.04 and p = 0.0015, respectively). According to the definition of Drossman, patients with OD appeared to be constipated not because of a defaecation frequency of < 3 times a week but because of excessive straining. Constipation improved significantly after, and constipation was not induced by, RVP. Faecal incontinence scored according to Browning and Parks decreased significantly (p = 0.0007). RVP restored anatomy: all (13) enterocoeles, all (25) but 1 internal intussusception, and 20 of 32 rectocoeles dissolved while remaining rectocoeles were reduced in size. Decrease in grades of incontinence was correlated to decrease in grade of intussusception and decrease in constipation was correlated to decrease in grade of rectocoeles although not significantly (r = 0.59, p = 0.09 and r = 0.41, p = 0.11, respectively). Maximal anal resting pressure was unchanged while squeeze pressure decreased (p = 0.02). Rectal sensibility to distension was unchanged and rectal electrosensibility improved (p = 0.04). Conclusion: RVP reduces obstructed defaecation (OD) and faecal incontinence (FI) if patients are selected for operation based on symptoms and anatomic abnormalities on defaecograms. Postoperative constipation was not induced.
of Medicine
47 (1995)
AI -A42
colitis. Nevertheless, there remains the possibility of failure. We reviewed the results of our hand-sutured IAPA(HS-IAPA) to look for patterns of failure in an attempt to improve results. Between 1984 and 1990 76 patients received a HS-IAPA with deviating ileostomy. Forty-five were male and 31 female. Ages varied from 11 to 61 years (mean 33 years). Twenty-three patients had familial polyposis coli (FPC), 52 ulcerative colitis (UC) and 1 had Crohn’s disease. Twenty-two patients had their pouch removed. Eleven were male. Ages varied from 18 to 61 years (mean 34). Twenty-one patients had UC and 1 had FPC. Nine patients had preoperative prednisone average daily dosage 20 mg. In 16 patients the ileostomy was closed after 150 days on average. Twelve patients had leakage of the ileo-anal anastomosis, 8 before and 4 after the ileostomy was closed. Seven of the 16 patients who had closure of their ileostomy had faecal continence disorders: 2 soiling, 1 insufficiency and 4 total incontinence. Pouchitis occurred in 12 patients. Three patients developed a peri-anal fistula, 5 a pouch-vaginal fistula. Defaecation frequency during the day varied from 4 to 15 (mean 9) and at night from 2 to 5 (mean 3). In the group of 54 patients who still have a pouch its function is acceptable. Average defaecation frequency during the day is 6 and at night 1. Thirteen patients in this group have continence disorders: 8 soiling, 1 insufficiency and 4 incontinence, which is conservatively treated. Seven patients had their pouch removed because of leakage of the anastomosis and accompanying pelvic sepsis. Five patients all operated for UC had their pouch removed due to uncontrollable pouchitis. In 6 patients the pouch was removed because of faecal incontinence. Four patients experienced a pouch failure due to a pouch-vaginal fistula. The mean interval between pouch construction and failure was 2.5 years (6 days-8 years). The rate of pouch failure was highest in the first postoperative year. Pelvic sepsis, enhanced by previous colectomy and preoperative usage of prednisone, was the cause of early failure (before ileostomy closure). Pouchitis, incontinence and fistulas were causes of late failure (after ileostomy closure). In this study 76 patients had a HS-IAPA with diverting ileostomy. Cause of early pouch failure was pelvic sepsis, influenced by previous colectomy and preoperative use of prednisone. Causes of late pouch failure were incontinence, pouchitis and fistulas. Between 1990 and 1993, 66 patients received a double-stapled ileoanal pouch anastomosis. In the double-stapled group no pouch was lost. The influence of colooic involvement recurrence after ikocolonic resection
on postoperative surgical for Crohn’s disease. E.
de Jong ‘, J.F.M. Slors ‘, G.N.J. Tijtgat ‘, D.J. Gouma ‘. ikoanal pouch anastomosis. W.F. van Tets i, J.H.C. Kuypers ‘. Department of Surgery, I Bosch Medical Centre, Den Bosch, 2 University Hospital, Nijmegen, Netherlands. Pouch
failures
after
Since its introduction in the early 1980s the ileoanal pouch anastomosis (IAPA) is most acceptable to the patient and surgeon in the treatment of polyposis coli and ulcerative
Department of I Surgery Medical Centre, Amsterdam,
and 2 Gastroenterology, Netherlands.
Academic
Follow-up after ileocolonic resection for Crohn’s disease is characterised by a high incidence of recurrence at the anastomotic site and subsequent reoperative surgery. It is still not known which factors contribute to this high incidence of recurrence, but in the literature it is suggested that concomi-