Paulino Martínez Hernández-Magro

Antiperistaltic ileal segment in ileoanal “J” pouch surgery

Ileal pouch anal anastomosis (IPAA) is currently the operation of choice for most patients suffering familial adenomatous polyposis (FAP) and ulcerative colitis (UC) with poor or no response to medical treatment. This procedure avoids permanent ileostomy and cures patients of their disease. This operation is nearly ideal because it removes all the affected mucosa while preserving the anal route of defecation, and patients are restored to their way of life with a quality of life superior to patients with conventional ileostomy. On the other hand, reversed (antiperistaltic) intestinal segment have been mentioned for the treatment of patients suffering from four conditions: dumping syndrome, postvagotomy diarrhea, massive bowel resection syndrome, and chronic uncontrolled diarrhea. It has clearly been demonstrated that antiperistaltic bowel segments produced marked and progressive delay in intestinal transit time, sustained improvement in fat absorption, and body weight increase. One of the main complaints of the patients submitted to IPAA is the increased frequency of bowel movements. We believe that this condition could be improved with the construction of an antiperistaltic ileal segment above the pouch. We report a 54-year-old female patient with a 3-year history of severe UC (pancolitis) and poor response to medical treatment despite of high doses of mezalamine and steroids. The patient reported the presence of waterymucous diarrhea and rectal bleeding at several times and important weight loss. She was informed about her situation, and we both decided to include her in a schedule for surgical treatment. The patient was hospitalized. Her weight at the time of admission was 121 lb and her height was 71 in., with a body mass index of 17. She received usual colonic preparation and antibiotic prophylaxis. Her preoperative laboratories were within normal ranges. She was submitted to total proctocolectomy and reconstruction with a 15-cm length “J” shape pouch, using double-stapling technique. Before the stapling of the pouch, we construct an antiperistaltic ileal segment of 10 cm of length, approximately 20 cm above the pouch. The ileal segment was isolated with intact vascular pedicle, rotated counterclockwise through 180°, and reanastomosed in continuity with a two-layer anastomosis in the distal segment. The proximal segment and the distal segment of the ileum were brought through the skin as diverting ileostomy and mucous fistula, respectively. The pouch was stapled to the anal canal, and the abdominal wall was closed in the usual fashion. The postoperative course was uneventful and she was discharged at the 5th postoperative day. Awater-soluble enema pouchgram was performed 12 weeks later, which revealed an intact pouch, and at that time, we decided to take down the ileostomy with the usual technique. In a postoperative contrasted study, we found a delay in normal intestinal transit in the area of surgery. Four months after being discharged, the patient referred three to four bowel movements per day and one bowel movement sometimes at night. But one of the most evident changes in her body habits was her increased on body weight. The patient gained 29 lb, and she has no bouts of pouchitis until present time. Int J Colorectal Dis (2006) 21:734–735 DOI 10.1007/s00384-006-0175-9

Antiperistaltic ileal segment in ileoanal “J” pouch surgery: Functional results could be improved?

Ileal pouch anal anastomosis (IPAA) is currently the operation of choice for most patients suffering familial adenomatous polyposis (FAP) and ulcerative colitis (UC) with poor or no response to medical treatment. This procedure avoids permanent ileostomy and cures patients of their disease. This operation is nearly ideal because it removes all the affected mucosa while preserving the anal route of defecation, and patients are restored to their way of life with a quality of life superior to patients with conventional ileostomy. On the other hand, reversed (antiperistaltic) intestinal segment have been mentioned for the treatment of patients suffering from four conditions: dumping syndrome, postvagotomy diarrhea, massive bowel resection syndrome, and chronic uncontrolled diarrhea. It has clearly been demonstrated that antiperistaltic bowel segments produced marked and progressive delay in intestinal transit time, sustained improvement in fat absorption, and body weight increase. One of the main complaints of the patients submitted to IPAA is the increased frequency of bowel movements. We believe that this condition could be improved with the construction of an antiperistaltic ileal segment above the pouch. We report a 54-year-old female patient with a 3-year history of severe UC (pancolitis) and poor response to medical treatment despite of high doses of mezalamine and steroids. The patient reported the presence of waterymucous diarrhea and rectal bleeding at several times and important weight loss. She was informed about her situation, and we both decided to include her in a schedule for surgical treatment. The patient was hospitalized. Her weight at the time of admission was 121 lb and her height was 71 in., with a body mass index of 17. She received usual colonic preparation and antibiotic prophylaxis. Her preoperative laboratories were within normal ranges. She was submitted to total proctocolectomy and reconstruction with a 15-cm length “J” shape pouch, using double-stapling technique. Before the stapling of the pouch, we construct an antiperistaltic ileal segment of 10 cm of length, approximately 20 cm above the pouch. The ileal segment was isolated with intact vascular pedicle, rotated counterclockwise through 180°, and reanastomosed in continuity with a two-layer anastomosis in the distal segment. The proximal segment and the distal segment of the ileum were brought through the skin as diverting ileostomy and mucous fistula, respectively. The pouch was stapled to the anal canal, and the abdominal wall was closed in the usual fashion. The postoperative course was uneventful and she was discharged at the 5th postoperative day. Awater-soluble enema pouchgram was performed 12 weeks later, which revealed an intact pouch, and at that time, we decided to take down the ileostomy with the usual technique. In a postoperative contrasted study, we found a delay in normal intestinal transit in the area of surgery. Four months after being discharged, the patient referred three to four bowel movements per day and one bowel movement sometimes at night. But one of the most evident changes in her body habits was her increased on body weight. The patient gained 29 lb, and she has no bouts of pouchitis until present time. Int J Colorectal Dis (2006) 21:734–735 DOI 10.1007/s00384-006-0175-9