Ileoanal Reservoir Research Articles

Intrapelvic reservoir with direct anal anastomosis

To reduce the frequency of bowel movements following colectomy and proctomucosectomy today three major types of ileoanal reservoirs are in use: the S-, J- and H-pouch. Approximately 2000 such operations have been performed throughout the world. Although only one postoperative death has been recorded, postoperative morbidity remains high. Our own results as well as a review of the literature confirms: 1) satisfactory sphincter control on continence; 2) retained discrimatory sensitivity; 3) reduction of daily bowel movements 4-7; 4) social rehabilitation. The difficulties of the procedure call for the referral of patients to centers specializing in these techniques.

Investigations of the anal sphincter before and after restorative proctocolectomy

Twenty-eight patients who underwent sphinctersaving proctocolectomy and formation of an ileoanal reservoir had clinical evaluation of resting and maximal anal sphincter pressures and perfused catheter manometry. The clinical estimate of resting tone, heretofore believe to be a good predictive parameter of postoperative function, was inaccurate. This suggests the advisability of manometric evaluation. There were significant changes in sphincter pressures postoperatively. Operation did not effect the preoperative electromyographic findings of the puborectalis muscle and external sphincter in our small postoperative population The mechanism by which operation might influence these parameters has been discussed. Factors such as parity and the descending perineum syndrome may effect continence. Due to the length of time the sphincter is required to function in these patients and the multiplicity of factors involved, we believe that long-term studies are needed.

A stapled S-shaped ileoanal reservoir.

An S-shaped ileoanal reservoir has the advantage of greater ease in obtaining adequate length for safe anastomosis vs. the J-pouch. The hand-sewn S-shaped pouch, however, takes considerably longer (70 vs. 20 minutes) to construct than either a hand-sewn or stapled J-pouch. Because of potential necrosis of the central bridge of tissue created between two longitudinal stapled lines in an S-pouch, the same techniques of stapling a J-pouch cannot be used in an S-pouch. The authors have developed a safe, rapid, stapling technique for construction of an S-pouch in the dog and have used it with success in four patients.

Ileoanal reservoir for ulcerative colitis and familial polyposis.

Although total proctocolectomy with permanent ileostomy is regarded as the definitive therapy for ulcerative colitis and familial polyposis, psychologic and physical complications with this operation have stimulated the development of the operation of total abdominal colectomy, mucosal proctectomy, ileal reservoir, and ileoanal anastomosis as an alternative surgical procedure. Since 1980, 104 of these operative procedures have been completed with no operative mortality; experience has been gained with both the J- and S-type reservoirs. Despite an appreciable number of postoperative complications, satisfactory function of the reservoir has been achieved in 86 of 91 patients followed up for at least three months after closure of the ileostomy. The remaining five patients have required reinstitution of fecal diversion. Functional results have not differed between two-limbed and three-limbed reservoirs. This operation must be considered a viable alternative in patients with ulcerative colitis and familial polyposis.

Radiology of the ileoanal reservoir.

The radiology of the ileoanal reservoir based on a study of 50 consecutive patients is presented. Small-bowel obstruction (12%) and leakage at the ileoanal anastomosis (8%) were detected most commonly. Partial outlet obstruction from reservoirs fashioned from three segments of terminal ileum was noted radiographically as a common problem unique to this form of ileoanal reservoir. Superior mesenteric artery syndrome (6%), pelvic abscess (4%), pouch-vesicular fistula (2%), and several other problems were less frequent.

The role of the ileoanal reservoir in patients with ulcerative colitis and familial polyposis.

The role of the ileoanal reservoir in patients with ulcerative colitis and familial polyposis.

Myoelectric and motor activity of the terminal ileum after pelvic pouch for ulcerative colitis.

The electrical and motor activity of the terminal ileum after proctocolectomy and ileoanal reservoir was evaluated in seven patients who had undergone surgery for ulcerative colitis. Recordings were carried out with an intraluminal probe under fasting conditions, during stepwise distention of the pouch, in the postprandial state and after administration of Prostigmine and bisacodyl. Ileal sensitivity was also studied. Phase III of the interdigestive myoelectric motor complex, when detectable (four patients), was characterized by regular spike bursts superimposed on slow waves at a frequency of 9 cycles per minute. Two different types of motor patterns were observed: short phasic waves lasting 2 to 6 seconds and long tonic waves lasting up to 2 minutes. In most cases, the amplitude and frequency of the pressure events were higher in the efferent limb than in the reservoir. Electrical activity of the surrounding rectal muscle and striated sphincters was also recorded. When distended to the maximum tolerable volume, the reservoir showed spike bursts propagated aborally at a frequency of 15 per minute, leading to large propulsive waves. An overall increase of spike activity was observed after a meal, which did not affect the slow waves. Neostigmine caused an irregular increase of electrical and motor activity, more evident in the efferent limb. Bisacodyl, used to test the functional integrity of the myenteric plexus, elicited strong propulsive contractions and urgency. Leakage did not occur frequently either at rest or under stimuli. Onset of sensation was elicited with volumes of 271 +/- 149 ml (Mean +/- SD) in the reservoir and 17 +/- 6 ml in the efferent loop of small bowel (P less than 0.001). 1) most of the electrical and motor properties of the terminal ileum are retained after surgery; 2) due to its large capacity, the reservoir acts as a storage organ; and 3) overall motility is reduced in the pouch when compared with the distal ileum and propulsion in the triple-loop system is opposed by the activity of the anal sphincters.

Management problems associated with ileoanal reservoir.

Management problems associated with ileoanal reservoir.

Alternatives to Conventional Ileostomy in Chronic Ulcerative Colitis

As long as surgeons have performed total proctocolectomy with permanent ileostomy, efforts have been made to avoid the necessity for a permanent stoma. Preservation of sphincter function can now be achieved by more liberal application of the operation of abdominal colectomy and ileorectal anastomosis in carefully selected patients, and knowledge of the progression from dysplasia to cancer can be applied in a prospective fashion to those persons potentially at risk who have retained rectal mucosa. Individuals who are incapable of dealing with conventional permanent ileostomy and who lack the potential use of their own sphincters can be offered the alternative of a continent ileostomy. The advantages of both of these procedures can be combined by greater application of the operation of total abdominal colectomy, mucosal proctectomy, and ileoanal reservoir with ileoanal anastomosis. Although enthusiasm exists for all of these procedures, their results should be compared with the results of what must still be considered the "gold standard" operation, that is, proctocolectomy and conventional ileostomy. Nevertheless, the alternative procedures represent a considerable advance in the overall care of patients with chronic ulcerative colitis.

Ileoanal reservoir: functional results and management.

Restorative proctocolectomy with ileoanal reservoir is an alternative to Brooke ileostomy. This study of 56 patients emphasizes functional results and management of the loop ileostomy, transient incontinence, frequency of bowel function, constipation, perianal skin, and psychosocial issues.

Proctocolectomy with ileoanal reservoir. An alternative to permanent ileostomy.

Proctocolectomy with ileoanal reservoir. An alternative to permanent ileostomy.

Restorative Proctocolectomy with Ileal Reservoir and Ileoanal Anastomosis for Ulcerative Colitis and Familial Polyposis

Our experience with the technique of restorative proctocolectomy utilizing a rectal mucosectomy, total colectomy, and ileal reservoir with ileoanal anastomosis in 56 patients with ulcerative colitis or familial polyposis is presented. 3 patients (5 %) had their pouch excised and represent failures of the operation. The current functional results are very encouraging but the potential for morbidity is high. The proper role of this procedure in the management of patients with ulcerative colitis or polyposis is currently being defined. In selected patients who are relatively fit, stable, and reliable and cognizant of the nature of this procedure and its alternatives, the ileoanal reservoir pull-through procedure is a reasonable option.