Pouch Motility Research Articles

P0653 Patients with ileo-anal J-Pouch display altered, higher pouch contractility than controls as measured with motility MRI

Abstract Background After colectomy, many patients with ileo-anal pouch anastomosis develop high bowel frequency and become refractory to antimotility agents despite normal pouch morphology. Recently, it has been shown that Liraglutide but not placebo reduces bowel frequency1. We investigate the potential underlying contractility (hereafter referred to as ‘motility’) of the pouch with motility MRI (which measures regional peristalsis) in this retrospective study. Methods 30 patients with ileoanal pouches (mean age 44 years, 9 female) and 10 controls (mean age 44, 5 male: 5 with non-colonic Crohn’s disease, 5 with ulcerative colitis) underwent standard MR Enterography including motility ‘cine’ imaging. All pouches were delineated by an experienced sub-specalty radiologist (Entrolytics, Motilent, UK). Clinical observations were extracted from medical records by a sub-speciality Gastroenterologist. Motility assessment of the pouch/rectum was performed using GIQuant (Motilent, London, UK) with a bowel wall contour placed at the pouch, to produce a numerical score for pouch/rectum wall motion.We 1) compared pouch against normal rectum, 2) compared pouch motility in the cohort separated by inflammation activity as seen on pouchoscopy, 3) compared frequency against pouch motility and finally 4) against symptoms via clinical assessment from patient notes. Non-parametric statistics were used. Results 1. Mean pouch motility score was 157 (25 to 391) and in controls was 59 (23 to 104). Difference of 98, P = 0.002. 2. Patients with pouchoscopy were dichotomised into normal vs non-normal. Endoscopically normal pouch had motility of 185 vs 119, P = 0.05. 3. Based on Pouch Frequency, when dichotomised into =>10 (bowel movements) and <10 (bowel movements), pouch motility was 205 vs 116, a significant difference of 88 units P = 0.007 and correlation of bowel movements with motility showed positive relationship, Rho = 0.46, p =0.01. 4. Based on Patient Reported Symptoms, dichotomised as ‘symptomatic’ vs ‘coping,’ pouch motility was 183 vs 132 with a non-significant difference of 50 units P = 0.1. Conclusion J-Pouch demonstrates markedly altered physiology with an elevated contractility phenotype, in terms of peristalsis, compared to disease-free controls. Pouch motility was associated with pouch frequency providing supportive mechanistic evidence for the efficacy of Liraglutide1. A weaker association was seen with pouchoscopy and symptoms which may now be followed up in an appropriately powered study.

Gastric Emptying of Semisolids and Pouch Motility Following Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding (LAGB) has been popularized as an effective, safe, minimally invasive surgical technique for the treatment of morbid obesity. We performed a pilot study to evaluate gastric emptying of semisolid meals and antral motility following LAGB. Gastric emptying half-time was compared in normal volunteers and morbidly obese patients before and 6-12 months after LAGB using sulfur colloid-labeled semisolid meals. There was no difference in mean age between groups. Women were prevalent in the group of obese patients. BMI was higher in patients before surgery (p < 0.001). Patients following LAGB demonstrated prolonged gastric pouch emptying (T1/2 = 36.6 +/- 9.8 min) compared to subjects without surgery (23.8 +/- 4.7 min) and healthy volunteers (22.8 +/- 6.8 min; p < 0.001). Similar gastric contractility was found all groups (3.3 +/- 0.4; p = 0.968). No cases of band slippage or pouch dilatation were observed during mean follow-up of 11.4 months. A standard normal gastric pouch emptying rate of semisolids in asymptomatic patients after LAGB was established. Postoperative prolongation of gastric emptying is a matter of mechanical delay without gastric pouch denervation. This study provides a first step of future functional evaluation of complications following this type of bariatric surgery.

Motility of the pouch correlates with quality of life after total gastrectomy

Jejunal pouch reconstruction is used to provide reservoir function after total gastrectomy, but controversy remains regarding pouch functions and quality of life (QOL). In this study, pouch motility was studied in conjunction with postoperative QOL. Pouch motility of 23 patients with jejunal pouch interposition after total gastrectomy was examined by manometry under fasting conditions and by an emptying test using dual-scintigraphy under postprandial conditions. Residual food was graded by endoscopic examinations. QOL was evaluated using the Gastrointestinal Quality of Life Index, and a stasis- or dumping-related symptom score. The pouch showed interdigestive contractile activity. Bursts of contractile activity occurred frequently and were long-lasting compared with the migrating motor complex phase III of the control jejunum. The percentage of time of contractile bursts correlated with postprandial pouch emptying (liquid: R(2) = 0.229, P < .03; solid: R(2) = 0.243, P < .02). Patients with little or no residual food had more percentage of time of contractile bursts than those with moderate residual food (P < .01). The percentage of time of contractile bursts was correlated with the Gastrointestinal Quality of Life Index score (R(2) = 0.262, P < .02), stasis-related symptoms (R(2) = 0.279, P < .01), and dumping-related symptoms (R(2) = 0.218, P < .03). An interposed jejunum pouch showed bursts of contractile activity that affected postoperative gastrointestinal function and patient QOL.

Defecation mechanisms after anterior resection with J-pouch-anal and side-to-end anastomosis in dogs

Colonic J-pouch-anal anastomosis or colonic side-to-end anastomosis is the reconstruction of choice after low anterior resection. However, the mechanisms of defecation after both reconstruction forms are still speculative. Low anterior rectal resections were performed in 12 dogs with six colonic J-pouch-anal (pouch) and six coloanal side-to-end (SE) reconstructions. Four months postoperative stool frequency, intestinal transit time, and neorectal compliance were determined by radiography and barostat. Defecation mechanisms were evaluated radiographically during expulsion of artificial stool. One dog with pouch reconstruction could not be evaluated due to an anastomotic leak, while the others had uncomplicated course. Spontaneous stool frequency was significantly increased with both reconstruction methods (control 2.0+/-0.9, pouch 2.7+/-1.2, SE 3.3+/-0.9 day; p<0.05). Intestinal transit time was significantly higher with pouch reconstruction due to storage of stool in the pouch and the descending colon compared to SE (control 760+/-82, pouch 592+/-97, SE 550+/-87 min; p<0.05). Compliance and functional capacity were higher in pouch than in side-to-end reconstructions (pouch 5.0+/-0.7 ml/mmHg, 124+/-23 ml; SE 2.7+/-0.3 ml/mmHg, 92+/-24 ml; p<0.05). During defecation, there were no contractions of the pouch detectable. The colonic J-pouch reconstruction results in better functional outcome than side-to-end coloanal anastomosis. Our results show that pouch evacuation is passive and independent from pouch motility. The functional principle of the colonic J-pouch is not its reservoir function but a delay of colonic motility.

Ambulatory manometric examination in patients with a colonic J pouch and in normal controls.

Anorectal function after anterior resection may be impaired as a result of reduced luminal capacity in the pelvis. The aim of this study was to evaluate the colonic J pouch neorectum by means of ambulatory manometry. Twelve patients with a colonic pouch following anterior resection and seven healthy controls were studied for a median of 6 (range 6-24) h using a probe with two pouch-rectal and two anal canal transducers. Records were interpreted by visual inspection. Pressure values and wave frequencies were determined by software analysis. Pouches had been functioning for a median of 32 (range 11-55) months. All patients with a pouch had an acceptable stool frequency. Seven of 12 patients complained of incomplete evacuation. Resting anal canal pressure (73 versus 100 cmH2O), pouch-rectal pressure (29 versus 15 cmH2O) and anal canal pouch-rectal pressure gradients (60 versus 85 cmH2O) were similar in patients and controls. The frequency of slow-wave activity in patients with a pouch was significantly lower than that in controls (7 versus 16 cycles per min, P = 0.001). Coordination between the colonic J pouch and the anal canal, in the form of sampling episodes, was observed in more than half of the patients with a functioning pouch. Large isolated contractions (pressure greater than 30 cmH2O and lasting longer than 20 s) and rhythmic contractions were the most frequent pattern of pouch motility.

Electrically stimulated colonic reservoir for total anorectal reconstruction.

Total anorectal reconstruction after abdominoperineal excision of the rectum has failed to achieve perfect continence. Electrically stimulated reservoir evacuation in combination with an electrically stimulated gracilis neoanal sphincter might improve results. A J pouch was constructed in an isolated colonic loop of seven dogs. Bipolar square wave pulses were delivered via two intramural stainless steel electrode pairs at 10 Hz. Stimulation parameters were varied to achieve adequate contraction. Serosal strain gauges recorded spontaneous and stimulated pouch motility. Evacuation was quantified by a volume displacement technique and observed fluoroscopically. Recordings were performed for a median of 3 (range 1-11) months. At 10 Hz and 0.5 ms pulse width, stimulation was required for 2 min and at voltages of 15 V (n = 4), 18 V (n = 1) and 20 V (n = 2) to obtain a contraction of amplitude comparable to that of a spontaneous contraction. Suprathreshold stimulation invariably resulted in colonic pouch contraction. The mean(95 per cent confidence interval (c.i.)) stimulus-response latency was 25.5(1.9) s. The mean(95 per cent c.i.) intraluminal pressure generated during stimulation was 114.1(17.0) cmH2O and 64.6(12.0) cmH2O during spontaneous activity (P < 0.001). In conclusion, electrical stimulation via intramural electrodes produced contraction generating sufficient intraluminal pressure to effect evacuation of a canine colonic pouch. This has potential for incorporation with an electrically stimulated neoanal sphincter in total anorectal reconstruction to improve evacuation and continence.

Ambulatory anorectal physiology in patients following restorative proctocolectomy for ulcerative colitis: Comparison with normal controls

The purpose of this study was to determine the manometric activity of ileoanal W pouch reservoirs following restorative proctocolectomy for ulcerative colitis and to compare the results with normal controls. Thirty-one studies were carried out; there were 15 controls (median age 52 years (range 29-80 years), 10 men, 5 women) and 16 pouch patients (median age 40 years (range 28-52 years), 13 men, 3 women). Mid-anal sphincter pressure and 'rectal' pressure were measured with a microtransducer catheter. The signals were digitalized and recorded in a portable electronic memory for later computer display and analysis. The system allowed the study of patients with minimal constraints while fully ambulant. The frequency of sampling (rectal pressure greater than or equal to sphincter pressure), sensation of flatus present and flatus being passed were 7(1-41), 3(1-7) and 1(0-3.5) per hour in the normal controls and 0(0-3), 0(0-1) and 0(0-1) respectively per hour in the pouch patients (P less than 0.001). Compared with the highly dynamic nature of the anorectum in normal subjects the patients with a pouch had very little activity. The sensation of pouch filling and the desire to defaecate were noted on 12 occasions and in six were associated with a rise in pouch pressure greater than 20 mmHg. One patient had nocturnal soiling and this was the only patient in whom frequent pouch contractions were noted. The results suggest that ileoanal pouch motility is usually quiescent and that incontinence in this group may be related to increased pouch activity.

Does Botulinum Type-A Toxin Affect Motor Activity after Proctocolectomy and Ileal Pouch-Anal Anastomosis?

Aim of the Study: The use of anticholinergic drugs has provided a useful therapeutic approach to reduce stool frequency in patients with proctocolectomy and ileal pouch-anal anastomosis (IPAA). Botulinum type-A (BTA) toxin has been shown to specifically block acetylcholine release in the intestinal wall. Therefore this study investigated the effect of BTA on small intestinal and J-pouch motility after IPAA. Material and Methods: Proctocolectomy and IPAA were performed in 4 dogs. The motility of the small intestine and the ileal pouch was recorded by serosal electrodes and strain gauge transducers. The intestinal transit time was determined radiologically and pouch compliance was determined manometrically. Multiple measurements were performed before and after endoscopic injection of BTA into the pouch wall. Results: This treatment did not significantly influence stool frequency, intestinal transit time or pouch compliance. Intrinsic pouch motility was characterized by irregular contractions, the amplitudes and frequencies of which remained unchanged after BTA administration. With the exception of lower contraction amplitudes directly proximal to the pouch, there were no significant differences in the characteristics of the migrating myoelectric complex or in the fed pattern of the small intestine and ileal pouch. Conclusions: BTA does not significantly affect ileal pouch motility. The beneficial effects of anticholinergic drugs therefore seem to be due to their multifactorial mode of action and not to the inhibition of cholinergic neurons in the pouch.

Defecation mechanisms after proctocolectomy and ileal pouch--anal anastomosis in dogs.

The role of intrinsic pouch motility after ileal pouch-anal anastomosis (IPAA) during defecation is still speculative. IPAA was performed in 12 dogs. Defecation mechanisms were evaluated by motility recordings during spontaneous defecation and during expulsion of an endoluminal balloon and by radiography with sequential sector-related gray scale analysis. Spontaneous defecations appeared without significant changes in electrical or mechanical activity of the pouch. Sequential filling of the pouch led to defecation in only seven dogs while the others did not succeed in emptying their pouch even with maximal balloon inflation. Neither strain gauge measurements nor electromyography demonstrated peristaltic contractions of the pouch during defecation while sector-related gray scale analysis revealed strong contractions of the abdominal wall during pouch emptying. Pouch emptying is independent of intrinsic pouch motility. The ileoanal pouch acts as a functionally passive reservoir, and its evacuation is initiated by a rise of the intra-abdominal pressure.

Effects of loperamide on ileoanal pouch function.

Opioid analogues are used to manage increased bowel frequency in patients with an ileoanal reservoir. The aim of the study was to determine the clinical efficacy of loperamide in patients with an ileoanal reservoir and to assess its effect on pouch motility. Fourteen patients with a pouch who had normal pouch emptying and anal function were studied. Ambulatory pouch and anal motility, and stool weights, were recorded for 24 h while taking no medication and for 24 h while receiving 8 mg loperamide. In a second analysis, patients were divided on the basis of bowel frequency into those with 4 or fewer motions (good function; n=6) and those with more than 6 per day (poor function; n=8), to determine any differential effects of loperamide. Loperamide decreased median bowel frequency (no loperamide 5.5 versus loperamide 4.0, P=0.03) and 24-h stool weight (610 g versus 413 g, P=0.03) but not individual stool weights. Patients with poor function had both higher bowel frequency (8.0 versus 3.5 per 24 h, P=0.004) and higher stool weight (728 g versus 430 g, P=0.05) with no treatment than those with good function. High-amplitude pouch pressure waves were greater in number before defaecation in patients with poor function and did not decrease with loperamide, in contrast to patients with good function. Pouch baseline pressure decreased after defaecation to a similar extent in both groups and was not affected by loperamide. Loperamide 8 mg per day reduces bowel frequency by reducing total stool weight, not individual stool weights. In patients with good function it also affects pouch motility. High bowel frequency is associated with increased pouch high-pressure waves.

The jejunal pouch as a rectal substitute after proctocolectomy

Our hypothesis was that a jejunal pouch used as a rectal substitute after proctocolectomy would slow enteric transit, delay defecation, and decrease stool frequency compared to an ileal pouch so used. Twelve dogs underwent proctocolectomy; six had a jejunal pouch-distal rectal anastomosis and six had an ileal pouch-distal rectal anastomosis. After recovery, postprandial mouth-to-anus transit was slower in jejunal pouch dogs (253 +/- 18 minutes [mean +/- SEM]) than in ileal pouch dogs (112 +/- 7.9 minutes; P <0.05). Moreover, jejunal pouch dogs passed only 4.1 +/- 0.3 stools during the 12 hours after eating, whereas ileal pouch dogs passed 6.3 +/- 0. 9 stools (P <0.05). The mean frequency of proximal ileal pacesetter potentials after feeding was less in jejunal pouch dogs (12 +/- 0.4 cycles/min) than in ileal pouch dogs (16 +/- 0.3 counts/min; P = 0. 01), and jejunal pouches had more action potentials (jejunal = 82% +/- 4.3% of pacesetter potentials had action potentials, ileal = 61% +/- 3.0%; P <0.05). In contrast, gastric emptying and pouch motility, emptying, mucosal integrity, and bacteriologic and histologic properties were similar in the two groups of dogs. We concluded that the jejunal pouch operation slowed enteric transit, delayed defecation, and decreased postprandial stooling compared to the ileal pouch operation.

Myoelectric and motor activity after proctocolectomy and ileal pouch–anal anastomosis in dogs

The aim of this study was to investigate the motor function of the ileoanal pouch and to evaluate its coordination with proximal small-intestine motility. Proctocolectomy and ileal J pouch-anal anastomosis were performed in 12 dogs. Motility was recorded by serosal electrodes and strain gauge transducers. Transmission of the migrating motor complex (MMC) on the pouch appeared in only 37 of 109 measurements. On the ascending limb there was a constant irregular activity with no MMC detectable. Motility pattern of the pouch did not change postprandially. Spontaneous defecation always appeared independently from MMC transmission without an increase of electrical or mechanical activity or endoluminal pouch pressure. Ileal pouch motility is independent from motility patterns of the proximal intestine. Its random contractile activity might provide storage function and make the pouch act as a functional reservoir. Intrinsic pouch motility is not responsible for pouch evacuation under physiologic conditions.

Pouch pressures and motility in relation to functional results of the ileal pouch-anal anastomosis

The aim of the present study was to evaluate pouch motility and sphincter function in relation to longterm functional outcome in ileal pouch patients. Nineteen patients with restorative proctocolectomy for ulcerative colitis were divided into two functional groups (good vs poor) on the basis of the frequency of defaecation and symptoms of soiling and faecal leakage, no patient used a pad during daytime. Ambulatory manometry with double-sensor micro-transducer was used to measure the pouch and sphincter pressures simultaneously in different postures during fasting (after defaecation), after a standardized meal and until desire for defaecation. There was no difference in sphincter pressures between the groups. Poor function was characterized by a higher resting pouch pressure in the lying position both after defaecation and at desire for defaecation. The resting pouch pressure was significantly higher in standing than in lying position in both groups. The median amplitude of pouch contraction pressure was higher in the group with poor than with good function. In conclusion functional disturbances in our patient population may be related to changes in the resting pouch pressure and motility.

URODYNAMIC FEATURES OF THE GASTRIC POUCH AFTER RADICAL CYSTECTOMY AND THE RELATIONSHIP TO ORAL INTAKE

We studied the motility of orthotopic bladder substitution with stomach (gastric pouch) in adults with bladder cancer and the effect of oral intake as measured on urodynamics. We also investigated the probable relationship between continence and sensitivity of the proximal urethra. Anticholinergic medication effects on pouch motility were tested. Six patients with a gastric pouch were questioned about quality of life 6 to 43 months after surgery, and examined urodynamically before and after oral intake. During the examination the proximal urethra (directly under the anastomosis between the pouch and urethra) was electrically stimulated to determine sensitivity. We tried to inhibit the peristaltic contractions with 20 mg. butylscopolamine intravenously. The main difference before and after oral intake was the onset time of peristaltic contractions. After eating the contractions began at a lower filling volume, which was statistically significant. There were no or insignificant differences in capacity and urodynamic parameters. We were successful in inhibiting the peristaltic contractions with anticholinergic medication. The gastric pouch is a valuable bladder substitute with sufficient volume, antireflux characteristics, satisfactory continence rate and adequate voiding behavior. Oral intake causes motor activity of the gastric pouch at a lower fill volume than fasting during urodynamic investigation. Anticholinergic medication may be useful for inhibiting peristalsis in the gastric pouch.

Ambulatory pouch and anal motility in patients with ileo-anal reservoirs.

Twelve patients were studied for a median of 18 hours (range 8.5-21.5 hr) by continuous, ambulatory, simultaneous pouch and anal manometry 10-85 months after restorative proctocolectomy. Two main patterns of motility were observed: (1) Large isolated contractions up to 68 cm H2O in amplitude and up to 67 seconds in duration were present in ten patients. These were often associated with the urge to defaecate and were more frequent before defaecation than after but did not appear to be associated with expulsion of faeces from the pouch. In two patients atypical large isolated contractions up to 378 cm H2O in amplitude were observed. (2) Rhythmic contractions at a frequency of 7-11 per minute and amplitude of 24-330 cm H2O, occurred for a duration of 18 seconds to 18 minutes in six patients. In the other six patients this motility pattern was not seen. Of the 12 patients nine were considered to have good function (five or less bowel actions per 24 hours) and three poor function (ten or more bowel actions per 24 hours). Rhythmic activity was the predominant motility pattern in all three with poor function whereas large isolated contractions predominated in those with good function, although there was considerable overlap in the types of motility observed between patients with good and poor function. Mean pouch pressure tended to be higher in patients with poor function than in those with good function both throughout the entire recording and during sleep. In a number of patients simultaneous anal recordings revealed the presence of slow waves and falls in pressure, some of which were associated with a simultaneous rise in pouch pressure.

Determinants of stool frequency after heal pouch-anal anastomosis

The aim of our study was to determine whether ileal pouch motility and evacuability and the 24 hour fecal output influence stool frequency after ileal pouch-anal anastomosis. In 23 patients, at a mean of 24 months postoperatively (range 22 to 26 months), ileal pouch motility was measured using an intraluminal bag and pressure-sensitive catheters. The pattern and efficiency of ileal pouch emptying was determined scintigraphically. A 24 hour stool collection was made and the stool output and stool frequency recorded. The volume of ileal pouch distention at which large amplitude propulsive waves appeared (the threshold volume) correlated closely with stool frequency. The larger the threshold volume, the fewer the stools per 24 hours (correlation coefficient -0.70; p less than 0.01). Also, the greater the 24 hour stool output, the greater the stool frequency (correlation coefficient 0.79, p less than 0.001). In contrast, the efficiency of ileal pouch evacuation was less strongly related to stool frequency (correlation coefficient -0.41, p = 0.05). We conclude that ileal pouch motility and stool output are major determinants of stool frequency after ileal pouch-anal anastomosis. Inefficient pouch emptying is less commonly associated with frequent bowel movements.

The role of motilin in periodic interdigestive pancreatic secretion in dogs.

The role of motilin in the periodic interdigestive secretion of the pancreas was studied in conscious dogs, each with a chronic gastric fistula, a Heidenhain pouch and a Thomas duodenal fistula. Motilin increased pancreatic water, bicarbonate and protein secretion and the motility of the stomach, duodenum and Heidenhain pouch in a manner which closely resembles the spontaneous changes which occur during interdigestive activity. Endogenous motilin released by duodenal alkalinization had the same effect as exogenous hormone. Continuous infusion of motilin did not cause continuous pancreatic secretion and gut motility but merely shortened the interval of the periodic interdigestive activity. Exogenous and endogenous motilin were ineffective following atropine. Hexamethonium abolished the pancreatic and duodenal peaks but not the changes in gastric and pouch motility induced by motilin or duodenal alkalinization.

Hormonal control of interdigestive motor cycles of canine proximal stomach.

Our aim was to determine whether the interdigestive motor cycles of the canine proximal stomach are hormonally regulated. In four dogs, a pouch of gastric fundus and orad corpus was completely extrinsically denervated by autotransplanting it the the left pelvis. Electrodes were implanted on the pouch, the main stomach, and the proximal small intestine. After recovery, intraluminal pressure was measured in the pouch during fasting, whereas electrical activity was recorded concurrently from the pouch, main stomach, and small intestine. Pouch motility was found to be cyclical, with bursts of large amplitude contractions occurring at intervals of about 1.8 h (108 ± 8; mean ± SE). The bursts of large amplitude contractions were found in the pouch at the same time that bursts of intense action potential activity were detected in the main stomach and duodenum. The interval between pouch bursts (108 ± 8 min) did not differ from the interval between duodenal bursts (107 ± 1 min, P > O.1), and the end of the pouch bursts preceded the end of the duodenal bursts by only 1 ± 1 min. Feeding 100 g liver abolished both pouch and duodenal bursts and decreased integrated pouch pressure from 11 ± 2 cmH 2 O· min before eating to 3 ± 1 cmH 2 O·min by 20 min after eating. We conclude that the interdigestive motor cycles of the canine proximal stomach and their abolition by feeding are hormonally regulated.

Effect of duodenal alkalinization on gastric motility

Summary Transplanted fundic pouches have been prepared using blood vessel anastomosis. These pouches and Bickel pouches have been used in a study of pouch motility in response to alkaline buffer solutions in the duodenum. Alkaline buffer solutions and pancreatic juice will stimulate motility in the denervated pouches. Pancreatic juice does not increase the p H sufficiently in the duodenum to stimulate the transplanted pouches. Atropine sulphate potentiates this stimulatory effect of alkaline solutions in the duodenum probably by inhibiting acid secretion by the residual stomach. Two mechanisms of action are postulated for this alkaline buffer effect; inhibition of the release of an inhibitory substance from the duodenal mucosa or release of a humoral stimulating agent.