John H. Pemberton

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.

Influence of splenectomy on survival rate of patients with colorectal cancer.

Between 1966 and 1980, 68 patients were identified who had a splenectomy before or concurrent with resection of a colorectal adenocarcinoma. Control subjects with concurrent disease were then matched with each study patient for age, sex, stage of disease, and date of operation. Follow-up was complete. Between splenectomy patients and control subjects, there was no difference in the site of primary disease (rectum versus colon), the number of patients receiving adjuvant therapy, the technique of resection (cure versus palliation), or the extent of regional disease. Overwhelming sepsis occurred in only one splenectomy patient. Splenectomy was associated with a significant decrease in survival at 5 years in patients with regional (stage C) disease but not in patients with localized (stage B) disease. More splenectomy patients received blood transfusions than control subjects, but an independent effect on survival could not be demonstrated. The mechanism responsible for this adverse impact of splenectomy is undefined. However, splenectomy should be considered a possible factor in the survival of patients operated on for regional colorectal cancer.

Preservation of continence after ileoanal anastomosis by the coordination of ileal pouch and anal canal motor activity

Nocturnal incontinence may occur after ileoanal anastomosis and may be related to loss of an effective anal canal pressure barrier during sleep; how pressure and contractions in the proximal bowel influence this barrier is unknown. Our aim was to evaluate the relationship between anal canal pressure and contractions and contractile activity of the pouch in continent subjects after ileal pouch-anal anastomosis (IPAA) and of the rectum in normal controls. A fully ambulatory system for 24-hour pressure recording was used. A flexible transducer catheter was introduced endoscopically so that sensors were at 2, 3, 8, 12, 16, and 24 cm from the anal orifice in 12 healthy controls (7 men, 5 women, mean age: 35 years) and 7 fully continent IPAA patients (4 men, 3 women, mean age: 34 years) more than 12 months postoperatively. Twenty-four hour spontaneous motor activity was stored in a 2.5 megabyte (MB) digital portable recorder. Mean anal canal pressure was calculated, and rectal motor complexes and ileal pouch large pressure waves were characterized. During sleep, resting anal canal pressures were similar in the two groups (72 +/- 12 mm Hg in controls versus 66 +/- 9 mm Hg in IPAA patients [mean +/- standard deviation (SD)], p = NS), but anal canal pressure showed cyclic relaxations (periodicity: 95 +/- 11 min in controls, 54 +/- 18 min in IPAA patients, p less than 0.05), during which the mean pressure trough was 15 +/- 4 mm Hg in controls and 14 +/- 5 mm Hg in IPAA patients (p = NS). In the control patients, during sleep, a mean of six rectal motor complexes were identified (range: 3 to 9). In patients with IPAA, during sleep, a mean of eight large pressure waves per hour were identified (range: 2 to 20). Importantly, in both controls and patients, rectal motor complexes or large pressure waves were always accompanied by rapid return of anal canal pressure from trough to basal values and increased contractile activity. We concluded that, in healthy patients and in continent patients after IPAA, motor activity of the rectum and of the ileal pouch was associated with changes in pressure and contractile activity of the anal canal so that rectal- and neorectal-anal canal pressure gradient, and, in turn, fecal continence were preserved.

Prolonged ambulatory recording of anorectal motility in patients with slow-transit constipation

Our aim was to determine phasic contractile activity of the distal bowel and anus in patients with slow-transit constipation; if readily identifiable patterns were present, prolonged recordings could confirm a diagnosis of slow-transit constipation. In 12 healthy control subjects and 11 women patients with slow-transit constipation (mean colonic transit time: 120 +/- 11 hours) and normal pelvic floor function, a flexible catheter was positioned endoscopically with sensors in the sigmoid colon, rectum, and anal canal in order to perform ambulatory recordings. A motility index (MI = mm Hg/h/100) was calculated during fasting and after feeding. Overall, the rectal MI and the frequency of anal canal contractions were less in the patients with constipation compared with those in the control group (rectum: 22 +/- 5 mm Hg/h/100 in the control group versus 13 +/- 10 mm Hg/h/100 in the constipation group; anal contractions/h: 23 +/- 7 in the control group versus 3 +/- 2 in the constipation group, p < 0.05). Moreover, in response to feeding, only control subjects had a significantly increased MI and frequency of anal canal contractions. Compared with control subjects, patients with slow-transit constipation had significantly reduced motor activity in the distal bowel and anal canal. Phasic contractile activity recorded during fasting and in response to a meal may be a means of confirming the diagnosis of slow-transit constipation in patients with borderline marker transit times.

Indwelling ileostomy valve device

Complications after construction of a continent ileostomy may require reoperation to restore continence. Although most patients accept another operation, a few refuse further operative intervention. In such patients we have employed an indwelling ileostomy valve device. A Silastic tube with a circumferential balloon to provide a leakproof seal functionally replaces the nipple valve that has failed. In 14 patients, the valve device has maintained continuous and voluntary control over evacuation without untoward local or systemic effects. If further investigation continues to support this approach to maintaining continence, use of an indwelling ileostomy valve device might be preferable to continued creation of the nipple valve.

Crohn's disease in ileal J-pouch.

To the Editor--Dr. Pezim and his colleagues report the outcome of indeterminant colitis after ileal pouch-anal anastomosis (Dis Colon Rectum 1989;32:653-8). We have experienced indeterminant colitis after ileoanal anastomosis in a patient in whom it was necessary to resect an ileal J-pouch because of incessant bleeding, five years later. A 20-year-old man had previously undergone restorative proctocolectomy and ileoanal anastomosis because of a preoperative diagnosis of ulcerative colitis in December 1983. Pathologic findings of the resected colon showed minimal chronic inflammatory infiltrate in the muscularis propria and a fissuring ulcer; no granulomas were seen. The pathologists diagnosed indeterminant colitis. Five years after the first surgical intervention, the patient complained of rebleeding and pus discharge from the anus. Colonoscopy revealed extensive inflammation in the ileal J-pouch. He did not respond to medical therapy. A diverting loop ileostomy did not decrease the bleeding and inflammation of the pouch. Resection of the ileal Jpouch was performed with patient consent in August 1988. The pathologic findings revealed deep transverse fissure formation, cobblestoning, and granulomas typical of Crohns disease. At this time, the pathologic diagnosis was Crohns disease. As indicated by Pezim et al., it is difficult to distinguish between ulcerative colitis and Crohns colitis preoperatively. It is occasionally difficult to distinguish between these two disorders based on clinical and pathologic characters, and to know whether ileoanal anastomosis should be performed in such cases of indeterminant colitis. Five years after ileal J-pouch anal anastomosis in a patient with indeterminant colitis, Crohns disease in the pouch could be diagnosed pathologically. Careful clinical and pathologic follow-up confirmed the correct diagnosis. With a diverting ileostomy, elemental diet therapy, hydrocor tisone and/or sulfasalazine, and total parenteral nutrit ion were concomitantly applied. Once Crohns disease has occurred, no effective conservative therapy can improve the clinical course, as in our case. There are no identifiable concepts concerning the apparent diagnostic characters to enable distinguishing Crohns disease from indeterminant colitis. Further study is needed to avoid the pitfalls presented in our case.