Restorative proctocolectomy with various types of reservoir.

Abstract

AbstractThe historical development of restorative proctocolectomy with ileal reservoir, indications, and technique are discussed. Results of the larger published series are compared with reference to different reservoir designs.A series of 152 patients treated by 2 surgeons using 3 different reservoir constructions is described. One hundred twenty‐eight patients had ulcerative colitis, 22 had familial adenomatous polyposis, and 2 had functional bowel disease. Reservoir types included triple loop (71), double loop (17) and quadruple (64) designs. The first reservoir type had a distal ileal segment as part of the construction, which was absent in the second two. There was 1 postoperative death (0.6%). Operative morbidity for both reservoir and ileostomy closure operations in the 3 reservoir groups was as follows: no complication, 44%, 47%, 63%; ileoanal anastomotic breakdown, 25%, 18%, 6%; and intestinal obstruction, 15%, 0%, 12%. Total in‐patient stay (days) for all necessary admissions was 38±16, 31±13, and 24±8. There were 10 (7%) failures [triple loop, 8 (11%); double loop, 1 (6%); and quadruple loop, 1 (1.5%)].Function was assessed in 123 patients (triple loop, 58; double loop, 14; and quadruple loop, 51). Mean follow‐up from closure of the ileostomy (months) was 47.6, 29.7, and 14.8. Frequency of defecation per 24 hours was 3.6±1.4, 5.5±1.4, and 3.3±1.0; night frequency (greater than 1 per week) occurred in 21%, 57%, and 14% of patients; 10%, 50%, and 20% required antidiarrheal medication. Frequency, night evacuation, and need for medication was significantly greater in the double loop group (p<0.05). Continence was normal in 76%, 79%, and 92%; minor mucous leakage occurred in 21%, 21%, and 8%; and fecal leakage in 3%, 0%, and 0%. There was 1 case of diminished erection but no other urinary or sexual dysfunction. Catheter evacuation was required by 54% of patients with triple loop reservoirs, and was not required in those with double or quadruple loop designs.Reservoir capacitance was inversely related to frequency, and compliance studied in 32 patients was significantly greater in quadruple than in double loop reservoirs (38.5 ml/cm water, 18.9 ml/cm water). Mean residual volumes after evacuation of a standard fecal bolus in the 3 reservoir groups were 14.1% (0–57%), 18.1% (0–30%), and 7.8% (0–35%) (not statistically significant).Histological chronic and acute inflammation in the reservoir occurred in 90% and 23%, respectively, of 92 patients studied. Based on a histological grading system, severity of acute inflammation was related to a diagnosis of ulcerative colitis. No relationship between inflammation (acute or chronic) and type of reservoir, compliance, capacitance, or emptying characteristics was found.Of the 3 designs used, the quadruple loop reservoir has had the lowest morbidity and best function with a failure rate of 1.5%, a low frequency of defecation (3.3/24 hours), incidence of night evacuation (14%), and medication required (20%) while maintaining normal continence in 92% of patients and spontaneous evacuation in all patients.