Procedures Conserving Continence in the Surgical Management of Ulcerative Colitis

Procedures Conserving Continence in the Surgical Management of Ulcerative Colitis

Symposium on Colon and Rectal Surgery Procedures Conserving Continence in the Surgical Management of Ulcerative Colitis ]. C. Goligher, M.D.* The e...

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Symposium on Colon and Rectal Surgery

Procedures Conserving Continence in the Surgical Management of Ulcerative Colitis

]. C. Goligher, M.D.*

The elective operation favored by most surgeons during the past 25 to 30 years for ulcerative colitis has been a one-stage ileostomy and complete proctocolectomy. This procedure is certainly a rational one for a condition usually involving the whole of the large intestine by the time it comes to surgical treatment. Moreover, wide experience has shown that it is generally followed by excellent results. 19 But, from the patient's point of view, this procedure has a great disadvantage-psychologic almost more than physical-that it entails acceptance of a permanent ileostomy and the wearing of an external bag to collect the feces. Admittedly with the high standard of stomal care now available, the inconveniences of such an arrangement have been very substantially reduced, and it is fair to claim that very few persons cannot manage to lead full and active lives despite an ileostomy. Nonetheless, colitis patients, who for the most part are relatively young, should naturally be eager to consider alternative forms of surgical treatment that will avoid a permanent stoma or will construct it so that continence is conserved and the necessity for using an external appliance is obviated. There are four possible choices. THE RESERVOIR OR CONTINENT ILEOSTOMY This type of ileostomy can be performed either at the initial proctocolectomy or-as I believe is usually preferable-as a conversion from a previous conventional ileostomy. Instead of the patient wearing an external bag, the surgeon makes an internal bag out of the terminal 50 em or so of ileum immediately proximal to the stoma. Kock, 26 who originated the procedure, initially thought that if the reservoir were constructed in a certain way it would be relatively aperistaltic and inert and would not discharge its contents of feces except when a rubber or plastic catheter was *Emeritus Professor of Surgery, 'The University of Leeds, England; Consulting Surgeon, St. Mark's Hospital for Diseases of the Rectum and Colon, London, England

Surgical Clinics of North America-Vol. 63, No. 1, February 1983

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Figure 1. Diagram of reservoir ileostomy with nipple-valve. (From Goligher, J. C.: Surgery of the Anus, Rectum, and Colon, Ed. 4. London, Bailliere-Tindall, 1980, with permission.)

passed into it through the external opening three or four times daily. In the intervals between intubations, it was hoped that the stoma could simply be covered by a piece of dry gauze and strapping. Unfortunately, it soon became evident that this was not entirely so, for fecal leakage also frequently occurred apart from intubation. This experience led to alterations in the technique of the operation: a projecting nipple-valve was created at the exit from the reservoir by intussuscepting the exit conduit into the reservoir for 4 or 5 em (Fig. 1). 28 With a valve of this kind, a completely continent reservoir could be contructed. But before long, it was found that these valves tended to be

Figure 2. Pantaloonogram radiographs of ileal reservoirs. A, Nipple-valve in position inside the pouch. B, Nipple-valve extruded, so that it has been impossible to pass tube into the reservoir. ( From Goligher, J. C.: Surgery of the Anus, Rectum, and Colon, Ed. 4. London. Bailliere-Tindall, 1980, with permission.)

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A Figure 3. Method now frequently favored for making the nipple-valve. A, Reservoir partly constructed by two lateral anastomoses in an S-shaped loop of ileum, the serosa, and muscle coat of the segment of ileum to be used for making the valve scored with diathermy, and a strip of Marlex mesh or aponeurosis threaded through holes in the related mesentery. B, Nipple-valve created by drawing bowel into open reservoir. Note the four staple lines on the valve. The sling of Marlex has been tightened and will be wrapped round the emerging ileum and sutured in place.

extruded from the reservoir with loss of continence. 22 • 27 The frequency of extrusion of the valve has varied from 10 per cent to over 40 per cent according to the surgeon 19• 20 and is unquestionably the major outstanding problem with this operation. Much thought has been devoted to improving the methods of construction and fixation of the valve at the initial operation. Currently a popular technique involves (1) the application of the SGIA stapler (U.S. Surg. Corporation) at four or five points around the circumference of the whole length of the nipple-valve and (2) the insertion of a strip of posterior rectus sheath or Marlex mesh through slits in the part of the ileal mesentery supplying the valve to retain it in place (Figs. 2 and 3). 10• 19• 20 • 30 This method seems to have been moderately successful in avoiding extrusion of the valve, 30 but a longer follow-up will be necessary to establish its real worth. Hulten and Fasth 25 argue a good case for establishing a loop ileostomy proximal to a reservoir ileostomy for two months or so to enable the valve to become firmly fixed before being subjected to any strong extrusive force. Though some surgeons such as Kock29 and Beahrs 7 are prepared to advise a reservoir ileostomy quite freely, I believe that for two reasons caution should still be exercised in offering it to patients. The operation

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may fail because of subsequent extrusion of the valve, and one or more reoperations may be required. This possibility should be clearly explained to the patient, as should the alternative of having a conventional ileostomy in the first instance and keeping the reservoir operation in reserve for use if the ordinary stoma ultimately proves unacceptable. Of course, if the newer methods of valve construction now under trial could control the tendency to valve extrusion, the indications for the operation on this score could be more liberal. The second reason for caution relates to the current wave of interest in trying to conserve continence by ileorectal or ileoanal anastomosis if the rectum remains to make this possible. This trend has restricted consideration of a reservoir ileostomy largely to patients who have already had a complete proctocolectomy and conventional ileostomy and are experiencing sufficient problems with the latter to make them try a continent ileostomy.

USE OF ARTIFICIAL OCCLUSIVE DEVICES IN ASSOCIATION WITH CONVENTIONAL ILEOSTOMY OR VALVELESS RESERVOIR ILEOSTOMY

When a few years ago the Erlangen magnetic ring closing device, 15 designed to render colostomies continent, was being evaluated, 20 it seemed reasonable to consider the possibility of using this arrangement also to confer continence on ileostomies. In fact, three or four cases with conventional ileostomies in Erlangen were given magnetic rings, but the results were disappointing, 24 · 49 because frequent "uncappings" of the stoma were necessary and because there were occasional leakages. It would be more logical to combine the magnetic closing device with a valveless reservoir ileostomy, using the device as a substitute for the nipple-valve, as was done in four or five cases at St. Mark's Hospital, London, 34 and in two of my patients. But, here again, the results were not entirely satisfactory, for, as with colostomies, continence was not always complete, and my patients complained that the device seemed to hang heavy in the abdominal wall. More recently, Beahrs et al. 6 have reported the use of an indwelling drainage tube as an obstructive device in patients with a reservoir ileostomy, which has become incontinent. The tube employed closely resembles an intratracheal anesthetic tube with an inflatable balloon, which on distention keeps the tube in position and helps to prevent leakage of feces alongside the tube when it is occluded. Pemberton et al. 44 have conducted some interesting experiments with intermittent occlusion of conventional ileostomies in dogs and more recently in patients by means of such a tube. They have found it possible by obstructing the tube for longer times to produce an adoptive dilatation of the lower ileum, so that the occlusion can be maintained for up to 6 hours without discomfort or leakage. The patients are then able to use this arrangement as a substitute for wearing an ileostomy bag. How attractive this arrangement will be as a substitute for a conventional appliance remains to be seen.

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COLECTOMY AND ILEORECTAL ANASTOMOSIS

This operation has always excited controversy when used for the treatment of ulcerative colitis, for this disease almost invariably also involves the rectum. Obviously, therefore, a colectomy and ileorectal anastomosis for this condition means keeping and using an inflamed segment of large bowel, which would seem tantamount to an invitation to further trouble. However, what matters in Medicine-as in most other things in life-is, not what should happen but what actually does happen. Despite the residual rectal inflammation, many patients have an acceptable state of bowel function after ileorectal anastomosis and are very pleased with the outcome of their operation. In others, there is so much diarrhea and passage of blood and mucus or other symptoms from the persistent or recurrent proctitis, which resists medical treatment with steroid retention enemas, that further operative intervention to remove the rectum and establish an ileostomy eventually becomes necessary. The frequency of failure with ileorectal anastomosis has been variously estimated by different surgeons as ranging from 10 to 50 per cent, 18• 19 and in a recent report from the Cleveland Clinic23 it was 36 per cent. A rate of failure of nearly 40 per cent might at first sight seemed very disappointing, but conversely it could be stressed that just over 60 per cent of the patients never needed an ileostomy, and of the other 40 per cent who did, many managed to avoid it for several years. Apart from failure'due to persistence or recurrence of the proctitis and severe diarrhea is a very important and much disputed question: what is the patient's risk of a carcinoma subsequently developing in the rectal stump after an ileorectal anastomosis for ulcerative colitis. The most comprehensive examination of this topic is that of Baker et al. 5 who conducted a 22-year follow-up review of patients treated by this operation by Aylett, 2• 3 the leading European advocate of colectomy and ileorectal anastomosis for colitis. It revealed an overall incidence of carcinoma in the rectal stump of just under 6 per cent, the frequency being higher the longer the period of follow-up. Moreover, it seemed that in roughly 4 of those 6 per cent of cases the cancer had proved fatal or was likely to be so. Even more alarming is the recent report by Johnston26 on E. S. R. Hughes's series of cases treated by colectomy and ileorectal anastomosis for colitis, which records an incidence of cancer developing in the rectal stump of roughly 18 per cent. Clearly, the possibility of this complication is a very serious drawback to this operation. However, the development of most cancers in colitis may possibly be anticipated by detecting pronounced epithelial dysplasia on mucosal biopsies, as proposed and practiced by Morson and Pang, 37 Lennard-Janes et al., 32 and Dickinson et al. 11 This method is particularly appropriate for the survey of patients with a retained rectum after ileorectal anastomosis. If regular, multiple rectal biopsies had been secured, at least every 12 months after operation in Aylett's and Hughes's series of cases, many of their patients destined to develop carcinomas most likely had this predisposition detected at a premalignant stage and could have been submitted to a timely

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prophylactic proctectomy. Indeed, it is this ability to monitor the prospects of malignant change subsequently in the rectum by routine biopsies that makes colectomy and ileorectal anastomosis a more acceptable method of surgical treatment for ulcerative colitis than it formerly appeared to be. If regular supervision of this kind is not going to be possible, this operation should not be performed. In considering the selection of cases with colitis for this operation, the surgeon would do well if he could forecast accurately which patients would do well and which badly with an ileorectal anastomosis. Unfortunately, no entirely reliable guidelines of this kind are available, 4 though Adson et al. and Farnell et al. 13 formed the firm impression that younger patients did less well than older ones, and Lindham and Langercrantz33 report particularly unsatisfactory results with ileorectal anastomosis in children. This is especially disappointing, for they are the group of patients for whom avoidance of an ileostomy would be particularly appealing. It is customary and perhaps reasonable to restrict the use of ileorectal anastomosis to patients with relatively mild changes in the rectum and without fistulae, strictures, or indeed any significant fibrosis in the rectal wall, which would impair its elasticity and ability to distend postoperatively to form an effective fecal reservoir. Because systemic complications (arthritis, iritis, and skin manifestations) may not resolve completely if any part of the diseased large bowel remains, 19 colectomy and ileorectal anastomosis is better avoided in patients so complicated. Finally, it should be explained unambiguously to the patient that an ileorectal anastomosis is something of a gamble, which may or may not be successful, and that regular follow-up visits are an essential part of postoperative care. Accepting these criteria, I reckon that about 20 to 25 per cent of my patients coming to elective surgical treatment for ulcerative colitis in the last five years have been considered suitable candidates for a colectomy and ileorectal anastomosis. The operation can be performed as a primary procedure, when a temporary covering loop ileostomy may sometimes be desirable, or, as I prefer, as a second-stage operation six or 12 months after a previous ileostomy and subtotal colectomy. Whether the anastomosis is end-to-end or side-to-end is immaterial. A crucial consideration is the length of the retained rectal stump: neither should it be too short, or function may be poor, nor too long, or it may be difficult to bring all parts of the mucosa into view for biopsy with the rigid sigmoidoscope at follow-up visits. It is probably best to divide the bowel at the top of the rectum, about 15 em from the anal verge.

TOTAL COLECTOMY, FULL-THICKNESS PROXIMAL PROCTECTOMY, MUCOSAL DISTAL PROCTECTOMY, AND ILEOANAL ANASTOMOSIS WITH OR WITHOUT VALVELESS ILEAL RESERVOIR The latest contender for favor is this operation (Fig. 4), which was originally suggested by Nissen, 39 but is associated more with the name of Ravitch. 45 • 46 He believed that the nerve endings responsible for rectal

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Figure 4. Diagrams of ileoanal anastomosis (A) without reservoir and (B) with reservoir. Note temporary covering loop ileostomy. The amount of retained rectal muscle-coat shown in these diagrams is almost twice as long as is now usually preserved in this operation. (From Goligher, J. C.: Surgery of the Anus, Rectum, and Colon. Ed. 4. London, Balliere-Tindall, 1980, with permission.)

sensation resided in the rectal muscle coat, so that, even after the excision of the mucosal lining of the lower rectum, the normal sensory mechanism subserving anal continence should be retained. Moreover, he was able to report several cases of colitis and polyposis treated by this operation with very satisfactory functional results. 46 However, most other surgeons such as Wangensteen and Toon55 and myselfl 8 found that the operation was followed by very great frequency and urgency of defecation, so that the patients often could not control the escape of feces, especially at night, and were so uncomfortable that most of them eventually had an ileostomy performed. The consequence was that ileoanal anastomosis failed to secure any substantial measure of surgical support, though a few surgeons continued to use it, mainly for polyposis. 12· 48 What sparked the recent revival of interest in the procedure was the influential report of Martin et al. 35 on 17 children with colitis treated by the procedure. Fifteen of the children had good continence and acceptable bowel habits. Another important factor was the idea that incorporation of an ileal pouch immediately above the anastomosis might help these patients more quickly achieve better bowel function by providing a reservoir for the feces. Valiente and Bacon53 and Peck and Hallenbeck43 were the first to examine the value of such a pouch in conjunction with ileoanal anastomoses in the experimental animal, followed more recently by Ferrari and Fonkalsrud.14 The first clinical use of a combined ileal pouch and ileoanal anastomoses was apparently by Peck42 in the mid-1970s, but his method of contructing the pouch was so complex that most surgeons have preferred the simpler technique of making the pouch by two lateral anastomoses in an S-shaped loop of ileum, as advocated by Parks and Nicholls 40 and Fonkalsrud 16 and more recently also by Martin 36 , or by a single lateral anastomosis in a J-shaped loop, as favored by U tsunomiya et al. 53 and Beart. 8

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Apart from the dispute about the methods of preparing the reservoir, two other technical points have been controversial. One is the amount of rectal muscle coat that should be conserved. Martin et al., 35 Peck, 42 Utsunomiya et al., 53 and originally Tellander and Perrault, 50 and Fonkalsrud 16 attached great importance to subsequent function of keeping the muscle coat of most of the rectum. A tedious 2 to 3 hour dissection to remove the mucosa from that length of bowel is the disadvantage of this procedure. Moreover there is no convincing evidence that retaining this amount of muscle coat gives any better functional results than keeping just the muscularis of the distal third. Whether "rectal" sensation after these operations is generated by stretching the rectal muscle coat or by pressure of the distending rectum on the levator muscle is uncertain. 30 More recently, Tellander and Perrault52 and Fonkalsrud17 now save only the most distal 5 to 6 em, as do Parks et al. 41 and myself. Beart8 retains even less. But unlike Safaie-Shirazi and Soper48 and Martin et al., 35 who apparently conserved some of the anal canal mucosa, most surgeons now feel that in treating either colitis or polyposis with this operation the surgeon must remove all

the mucosa down to the pectinate line. The other point of discussion is how the operation should be staged. The total colectomy, construction of the reservoir, and ileoanal anastomosis (plus covering loop ileostomy) can be done in one stage, with subsequent closure of the ileostomy at a second stage at least two months later. A frequent alternative is a three-stage routine, comprising ileostomy and subtotal colectomy at the first intervention-often done elsewhere-the construction of the reservoir and ileoanal anastomosis (plus a new covering loop ileostomy) at the second stage, and closure of the loop ileostomy at the third. Naturally, the results of these more recent experiences with this type of operation are being scrutinized with great interest. One fact emerges from most of the reports, as from my own personal practice: the initial postoperative period may be marked by septic complications and partial anastomotic dehiscence, which may considerably delay the convalescence and postpone the eventual closure of the loop ileostomy. Furthermore, after the ileostomy has been closed, it may be some weeks or months before a really satisfactory state of bowel function and continence is achieved. A considerable time should be allowed to elapse before attempting to assess the outcome. One report on the use of mucosal protectomy with ileoanal anastomosis without an ileal pouch in children and teenagers comes from Tellander and Perrault, 51 who operated on 25 such patients with colitis or polyposis between 1977 and 1980. There were no operative deaths. One patient was found to have Crohn's disease and si.tbsequently had an ileostomy. Of the remaining 24 patients, seven patients had six or less stools per day, but 17 had seven to 12 stools in the 24 hours, and virtually all of them had to get up to defecate one to three times during the night. In addition, two had occasional incontinence at night. One patient has had to have an ileostomy. The authors consider the clinical result excellent in 11 patients, good in seven, fair in three, and poor in three. More recently, Tellander et al. 51 have had some encouraging experiences with dilating the ileum just above

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the anastomosis by periodic balloon distention during the interval before closing the loop ileostomy. Another report also on the use of ileoanal anastomosis without an ileal pouch but in adults is provided by Beart et al. 9 Their series comprised 48 patients with colitis or polyposis. There were no operative deaths. Because of early or later postoperative complications, the neorectum had to be sacrificed in six cases. In addition, four patients elected to keep the covering loop ileostomy indefinitely, which left 39 suitable for assessment of the funtional result. Nine opted to have a permanent ileostomy of conventional or reservoir type. In the remaining 30, the average frequency of stools in 24 hours was eight (range 3 to 20), six during the day and three at night. Most patients had some nocturnal seepage but made light of it. Dietetic restraint was frequently practiced to lessen the number of stools especially at night. Most patients used antidiarrheal drugs as well. Thus, of 48 patients, about 50 to 60 per cent had a fair or good result. Clearly, these results leave room for improvement, and Beart (1981) and his colleagues are now doing a further series of cases incorporating an ileal reservoir above the anastomosis. Clinically, they believe that this procedure has given better function. As for the results of ileoanal anastomosis with a pouch, perhaps the longest follow-up study is that of Peck42 who treated 29 patients with colitis or polyposis between 1970 and 1978 with no operative deaths. Twenty-five have had intestinal continuity restored. Seventeen (or 68 per cent) have six or fewer stools per 24 hours, eight have had more frequent stools or been converted to an ileostomy. Half the patients have to get up once or twice during the night to defecate, and about the same number experience some leakage of mucus or feces, especially at night. Roughly two thirds of the cases could be regarded as having good or satisfactory results. In general, patients with polyposis did better than those with colitis. Parks et al. 41 report on the results in 21 patients given ileoanal anastomoses with ileal pouches during the preceeding one to four years. There were no operative deaths. Three patients had pelvic abscesses, and intestinal obstruction due to adhesions developed in three, requiring reoperation. For function, one patient had to have an ileostomy. Of the remaining 20, ten evacuate the reservoir spontaneously, and ten intubate it per anum several times in the 24 hours. The frequency of evacuation ranges from one to six times in the 24 hours (mean 3.8). Nineteen patients do not have to get up at night. The frequency of evacuation has tended to diminish with time. During the day, all 20 patients are continent for feces and flatus, but two wear a pad to cope with mucous leakage. At night, five experience occasional leakage of mucus, and three of them wear a pad on that account. Nicholls et al. 38 analyze the functional results in these cases in more detail. From these reports, one might think patients given an ileal reservoir proximal to the ileoanal anastomosis seem to have less immediate diarrhea and achieve more rapidly an acceptable state of bowel function than do those submitted to ileoanal anastomosis without a reservoir. Perhaps intermittent peranal intubation of the reservoir is a useful initial measure in such cases.

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Figure 5. Radiograph after barium follow-through in a 19-yearold woman who has had an ileoanal anastomosis with ileal reservoir, showing the large pelvic pouch. She became pregnant and has recently been delivered of her baby by caesarean section.

My series of patients treated in the last four years by ileoanal anastomosis, all with an ileal reservoir, is relatively small-just 22 cases-for I have been very selective in my use of the procedure until some of the outstanding technical problems have been solved. There were no operative deaths. Four cases have been done too recently for evaluation of function. In the 18 suitable for assessment, the result was poor in two (one of whom has had the neorectum and pouch removed), fair in six, good in six, and excellent in four (Fig. 5). But these ratings might well be raised on more prolonged follow-up. Rightly or wrongly, in no patient has intermittent intubation been practiced. Altogether, despite some failures and indifferent results, I would feel encouraged by these achievements to continue to use the operation in well-motivated patients.

CONCLUSION

From the evidence available, in the surgical management of ulcerative colitis for the present, attempts to avoid a conventional ileostomy are apparently fully justified in a proportion of the patients, provided certain precautions are observed. If the rectum is still present, the possibility of an ileorectal anastomosis or of an ileal reservoir and ileoanal anastomosis should be considered. If these operations are deemed unsuitable or have been unsuccessfully tried-or if the rectum has already been removed-a reservoir ileostomy may be contemplated as an alternative to an ordinary stoma. Naturally, the patient should be fully apprised in advance of the respective prospects of success and failure with these various operations.

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REFERENCES 1. Adson, M. A., Cooperman, A. M., and Farrow, G. M.: Ileorectostomy for ulcerative disease of the colon. Arch. Surg., 104:424, 1972. 2. Aylett, S. 0.: Discussion on the surgery or ulcerative colitis. Proc. Roy. Soc. Med., 46: 1032, 1953. 3. Aylett, S. 0.: Three hundred cases of diffuse ulcerative colitis treated by total colectomy and ileorectal anastomosis. Br. Med. J., 1:1001, 1966. 4. Baker, W. N. W.: The results ofileorectal anastomosis at St. Mark's Hospital from 1953 to 1968. Gut, 11:235, 1970. 5. Baker, W. N. W., Glass, R. E., Ritchie, J. K., et al.: Cancer of the rectum following colectomy and ileorectal anastomosis. Br. J. Surg., 65:862, 1978. 6. Beahrs, 0. H., Bess, M.A., Beart, R. W., Jr., et al.: Indwelling ileostomy valve device. Am. J. Surg., 141: 111, 1981. 7. Beahrs, 0. H.: Personal communication, 1980. 8. Beart, R. W., Jr.: Personal communication, 1981. 9. Beart, R. W., Jr., Kelly, K. A., and Dozois, R. R.: Ileo-anal anastomosis in the adult. Surg. Gynecol. Obstet., 154:826, 1982. 10. Bokey, L., and Fazio, V. W.: The mesenteric sling technique-new method of constructing an intestinal nipple for the continent ileostomy. Cleve Clin. Q., 45: 1978. 11. Dickinson, R. J., Dixon, M. F., and Axon, A. J. R.: Colonoscopy and the detection of dysplasia in patients with long standing ulcerative colitis. Lancet 2: 620, 1980. 12. Drobni, A.: One-stage proctocolectomy with anal ileostomy. Dis. Colon Rectum, 7: 416, 1964. 13. Farnell, M. B., van Heerden, J. A., Beart, R. W., Jr., et al.: Rectal preservation in nonspecific inflammatory disease of the colon. Ann. Surg., 192: 249, 1980. 14. Ferrari, B. T., and Fonkalsrud, E. W.: Endorectal ileal pull-through operation with ileal reservoir after total colectomy. Ann. Surg., 136: 113, 1978. 15. Feustel, H., and Hennig, G.: Kontinente Kolostomie durch Magnet-Verschluss. Schwerz. Med. Wochenschr., 100:1063, 1975. 16. Fonkalsrud, E. W.: Total colectomy and endorectal ileal pull-through with internal ileal reservoir for ulcerative colitis. Surg. Gynecol. Obstet., 150: 1, 1980. 17. Fonkalsrud, E. W.: Personal communication, 1982. 18. Goligher, J. C.: The functional results after sphincter-saving resections of the rectum. Ann. Roy. Coli. Surg. Engl., 15: 316, 1951. 19. Goligher, J. C.: Surgery of the Anus, Rectum, and Colon. Ed. 4. London, BailliereTindall, 1980. 20. Goligher, J. C.: Current efforts to retain continence in the surgery of ulcerative colitis. Schweiz. Med. Wochenschr., 111:784, 1981. 21. Goligher, J. C., Lee, P. W. R., McMahon, M. J., et al.: The Erlangen magnetic colostomy closing device: Technique of use and results in 22 patients. Br. J. Surg., 64: 501, 1977. 22. Goligher, J. C., and Lintott, D. J.: Experiences with 26 reservoir ileostomies. Br. J. Surg., 62: 893, 1975. 23. Grundfest, S. F., Fazio, V. W., Weiss, R. A., et al.: The risk of cancer following colectomy and ileorectal anastomosis for extensive mucosal ulcerative colitis. Ann. Surg., 193: 9, 1981. 24. Hager, J., Schellerer, M., Botticher, D., et al.: The Erlangen magnetic closure system for colostomies and ileostomies. Sixth International Meeting of the Society of University Colon and Rectal Surgeons, Salzburg, Austria, 1976. 25. Hulten, L., and Fasth, S.: Loop ileostomy for protection of the newly-constructed ileostomy reservoir. Br. J. Surg., 68: 11, 1981. 26. Johnson, W. R.: Personal communication, 1981. 27. Kock, N. G.: Intra-abdominal reservoir in patients with permanent ileostomy. Arch. Surg., 99; 223, 1969. 28. Kock, N. G.: Continent ileostomy. In Allgower, M., Bergentz, S. E., and Caine, R. Y. (eds.): Progress in Surgery, vol. 12. Basel, Karger, 1973. 29. Kock, N. G.: Personal communication, 1980. 30. Kock, N. G., Myrvold, H. E., Nilsoon, L. 0., et al.: Construction of a stable nipplevalve for the continent ileostomy. Ann. Chir. Gynaecol., 69: 132, 1980.

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