Peter J. Holdsworth

Recovery of physiologic and clinical function after low anterior resection of the rectum for carcinoma: myth or reality?

PURPOSE: The aim of this study was to examine the serial changes that take place in the first year after low anterior resection for rectal carcinoma, in terms both of anorectal physiology and clinical bowel function. Our hypothesis was that some patients never regain satisfactory anorectal function, because the operative procedure leads to permanent impairment of anorectal reflex and motor function. METHOD: Nineteen patients underwent serial tests of anorectal function, before and for one year after low anterior resection. The median level of the anastomosis above the anal high-pressure zone was 3 (range, 1–6) cm. RESULTS: Anal resting pressure (median (interquartile range)) was significantly decreased three months after operation (62 (46–72) cm H2O) and one year after operation was still significantly less (58 (48–73) cm H2O) than before operation (77 (58–93) cm H2O)(P<0.01). Maximum tolerated volume in the neorectum decreased from 130 (88–193) ml before operation to 80 (51–89) ml three months after operation (P<0.005) but returned to preoperative values by six months (125 (60–140) ml) (P=not significant) and remained at these values one year after operation. The volume in the “neorectal” balloon required to elicit a maximum rectoanal inhibitory reflex was significantly less three months after operation than before operation (50 (43–60) ml compared with 100 (73–100) ml;P<0.005); one year after operation, the volume required was still significantly less than before operation (50 mlvs.100 ml) (P<0.015). Bowel frequency increased from 1 (1–2) in 24 hours before operation to 4 (2–5) times in 24 hours after operation and remained at 4 times in 24 hours throughout the first year after operation. Three months after operation, 53 percent of patients experienced some degree of fecal leakage and 24 percent experienced urgency of defecation. These aspects of bowel function improved with time, but even one year after operation, 29 percent of patients continued to experience fecal leakage and 18 percent wore a protective pad. CONCLUSIONS: Anal resting pressure decreased significantly after low anterior resection and did not recover in the course of the first year after operation. Moreover, the volume of an air-filled balloon in the neorectum that was required to elicit maximum inhibition of the anal sphincter was significantly less after anterior resection than before operation. These long-term and presumably permanent changes in physiologic behavior of the anoneorectum after low anterior resection provide an explanation for the failure of some patients to regain satisfactory bowel function following that procedure.

Quality of life after restorative proctocolectomy with a pelvic ileal reservoir compares favorably with that of patients with medically treated colitis

There remains some reluctance among physicians to refer patients for restorative proctocolectomy (RP). They argue that their patients would be worse off with a pouch because of the attendant problems of urgency and frequent bowel actions. The aim of this study was to compare quality of life in patients who had undergone RP with that of patients with ulcerative colitis on long-term medical treatment. A detailed questionnaire and the Hospital Anxiety and Depression (HAD) test were completed by 103 patients who had undergone RP and by 95 patients with ulcerative colitis on medical treatment and in remission attending a gastroenterology clinic. Patients with a pouch had a greater frequency of bowel action [five times per 24 hours (range, 4–7)vs.two times per 24 hours (range, 1–3);P<0.001] but less urgency of defecation [12/103 (11.7 percent)vs.69/95 (72.6 percent);P<0.001] than patients with medically treated colitis. Efficiency of evacuation, discrimination between flatus and feces, use of perianal pads, and perianal soreness were similar. Use of antidiarrheal medication was more common in the pouch group [53 of 103 patients (51.5 percent)vs.3 of 95 patients (3.2 percent);P< 0.05], whereas use of topical steroids was more common in medically treated patients [40 of 95 patients (47.1 percent)vs.9 of 103 patients (8.7 percent);P<0.05]. Limitation of social activity and HAD scores were significantly higher in medically treated patients. Quality of life for patients with a pouch appears to be as good as that for patients with medically treated colitis.

Stricture at the pouch-anal anastomosis after restorative proctocolectomy

PURPOSE: The aim of this study was to determine what factors may be responsible for the development of a stricture at the pouch-anal anastomosis after restorative proctocolectomy. METHODS: A consecutive series of 115 patients was studied retrospectively a median of 34 months (range, 4–100 months) after operation or ileostomy closure. The procedure failed in 11 patients (9.6 percent) who subsequently had to have a permanent ileostomy. Another two patients were excluded from the analysis, one of whom was awaiting ileostomy closure, whereas the other had a stricture due to a desmoid tumor. Of the remaining 102 patients, 39 (38 percent) developed an ileoanal anastomotic stricture, which was severe and persistent in 16 percent. RESULTS: The results were analyzed with the aid of multivariate logistic regression analysis. Factors which predisposed significantly to the development of an ileoanal anastomotic stricture were 1) use of the 25-mm (small) diameter stapling gun (P<0.05), 2) use of a quadruplicated reservoir (P=0.05), 3) use of a defunctioning ileostomy (P=0.03), and 4) anastomotic dehiscence and pelvic sepsis (P=0.03). The single patient whose operation failed because of a stricture had also developed pelvic sepsis associated with an anastomotic dehiscence. CONCLUSIONS: The eventual clinical, functional outcome after dilation of a stricture in the 39 patients who developed a stricture was as good as the outcome in the 63 patients who did not a develop stricture.

One-stage restorative proctocolectomy without temporary ileostomy for ulcerative colitis

PURPOSE: This study was designed to determine the safety of omitting a temporary defunctioning ileostomy in restorative proctocolectomy for ulcerative colitis. METHOD: One hundred consecutive patients with ulcerative colitis were treated electively by restorative proctocolectomy and pouch-anal anastomosis, without mucosal stripping; 50 had a defunctioning ileostomy added, and 50 underwent a one-stage procedure without ileostomy. RESULTS: There was no operative mortality. The incidence of postoperative complications was similar in the two groups of patients. Lifethreatening complications, however, were more common among patients who did not have a defunctioning ileostomy, of whom 11 developed pelvic sepsis and 7 required reoperation. Among patients with an ileostomy, seven developed pelvic sepsis but none required reoperation (P<0.02). Emergency reoperations were required in 11 patients without an ileostomy but in only 1 patient with an ileostomy (P<0.01). CONCLUSION: One-stage restorative proctocolectomy without a defunctioning ileostomy is associated with increased risk to life. Its routine use cannot be recommended.

Decrease in the anorectal pressure gradient after low anterior resection of the rectum. A study using continuous ambulatory manometry.

PURPOSE: Changes in anorectal function after low anterior resection of the rectum (LAR) often lead to symptoms of urgency and frequency of defecation, the anterior resection syndrome. It has been reported that preservation of part of the rectum improves clinical results, but why this should be remains unclear. METHODS: We have carried out continuous ambulatory manometric studies in two groups of patients: 11 patients, a median of 11 (range, 5–96) months after LAR, in whom the median anastomotic level above the anal high-pressure zone was 0 (range, 0–2) cm; 9 patients, a median of 6 (range, 3–12) months after sigmoid colectomy, in whom the rectum remainedin situ and who acted as controls. RESULTS: Comparing the LAR group with controls, resting anal pressures were lower, median 68 (range 27-102) cm H2Ovs. 95 (45–116) cm H2O (P<0.05), and neorectal pressures were higher, 25 (0–48) cm H2Ovs. 10 (0–10) cm H2O (P<0.01). Thus the anorectal pressure gradients were less, 34 (0–74) cm H2Ovs. 81 (35–113) cm H2O (P<0.01). Slow-wave activity in the anal sphincter was present in six patients (55 percent) after coloanal anastomosis and eight patients (89 percent) after sigmoid colectomy. Sampling episodes were seen in only two patients (18 percent) after coloanal anastomosis and five patients (56 percent) after sigmoid colectomy. When clinical endpoints were compared (LARvs. controls), bowel frequency in 24 hours was higher, 5 (3–8)vs. 2 (1–3) (P<0.01); fecal leakage was more common, affecting seven patients (64 percent)vs. one patient (11 percent) (P<0.05), and urgency of defecation was also more common. CONCLUSIONS: The inferior clinical results observed after LAR compared with the results after sigmoid colectomy are thus in part because of higher neorectal pressure acting on a weakened sphincter mechanism. These observations lend support to the idea that neorectal capacity should be increased in patients who undergo low anterior resection.

One-stage restorative proctocolectomy without temporary defunctioning ileostomy.

A temporary ileostomy has been employed routinely by most medical centers to defunction the ileal reservoir after restorative proctocolectomy. The aim of this study was to compare the clinical outcome in patients who underwent restorative proctocolectomy with and without the use of a temporary, defunctioning ileostomy. A consecutive series of 58 patients was studied. Each patient underwent restorative proctocolectomy with quadruplicated ileal reservoir and stapled pouch-anal anastomosis, without mucosectomy; 28 had a temporary, defunctioning ileostomy and 30 did not. The decision for or against an ileostomy was taken at the end of the operation. The two groups of patients were similar in age and sex distribution. There was no postoperative mortality. There were no significant differences in the incidence of pelvic sepsis, anastomotic stricture, and intestinal obstruction in patients without an ileostomy compared with patients with an ileostomy. The total length of stay in hospital after the operation was significantly reduced in the group of patients without an ileostomy (P<0.01). The avoidance of a temporary ileostomy did not lead to an increase in postoperative complications and was associated with a shorter length of stay in hospital after restorative proctocolectomy.

Comparison of triplicated (S) and quadruplicated (W) pelvic ileal reservoirs

Capacity and compliance, efficiency of evacuation, fecal bacteriology, fecal volatile fatty acids, mucosal morphology, and functional outcome were studied in 20 patients with triplicated (S) and 20 patients with quadruplicated (W) reservoirs after ileal pouch-anal anastomosis. Compared with patients with S reservoirs, patients with W reservoirs were found to have greater efficiency of evacuation of radiolabeled synthetic stool [97% (91%-98%) vs. 74% (62%-89%); P less than 0.05], and their reservoirs were more capacious [350 mL (320-400 mL) vs. 228 mL (175-290 mL); P less than 0.01] and compliant [16.0 mL/cm H2O (13.8-19.0 mL/cm H2O) vs. 12.3 mL/cm H2O (7.4-14.6 mL/cm H2O); P less than 0.01]. Effluent from S reservoirs contained significantly greater numbers of bacteroides (P less than 0.05) and concentrations of acetic and propionic acids (P less than 0.05) than effluent from W reservoirs. The degree of mucosal inflammation and villous atrophy in each design of reservoir was not significantly different. The ratio of anaerobes to aerobes in pouch effluent was significantly correlated with the degree of mucosal inflammation (rs = 0.433; P = 0.035). Fecal volatile fatty acids were significantly correlated with the percentage of stool retained after defecation and degree of mucosal inflammation. The frequency of bowel action was significantly less in patients with W reservoirs than in patients with S reservoirs [3.5/day (3-4/day) vs. 6.0/day (4-7/day); P less than 0.01]. The results indicate marked differences between these two ileal reservoir designs.

Internal anal sphincter activity after restorative proctocolectomy for ulcerative colitis: A study using continuous ambulatory manometry

PURPOSE: The aim of this study was to further investigate continuous ambulatory anal manometry which has recently been introduced as a method for studying anorectal activity in ambulant patients, thereby avoiding many of the potential drawbacks of static techniques. METHOD: In this study continuous ambulatory manometry was used to assess the activity of the internal anal sphincter in patients who had undergone restorative proctocolectomy, and, in particular, to compare patients who had undergone conventional mucosal proctectomy with sutured endoanal, ileoanal anastomosis with patients who had undergone restorative proctocolectomy with preservation of the entire anal canal by means of stapled, end-to-end, ileoanal anastomosis without mucosectomy. RESULTS: Evidence of basal internal sphincter activity was found in only 38 percent of patients after mucosal proctectomy with sutured endoanal anastomosis, whereas all patients after restorative proctocolectomy with stapled end-to-end anastomosis and all control individuals showed such activity of the internal sphincter. Similarly, the number of sampling episodes seen in patients after mucosal proctectomy with endoanal anastomosis was significantly less (median, 0.0/hours (0–30/hours)) than the number of sampling episodes observed in patients after end-to-end anastomosis (median, 4.5/hours (1–48/hours)) or in control individuals (median, 5.6/hours (0–31/hours)) (P<0.001). CONCLUSIONS: These results suggest that the internal anal sphincter is damaged in the course of mucosal proctectomy and endoanal anastomosis. In contrast, after restorative proctocolectomy with stapled, end-to-end anastomosis normal function of the internal sphincter is preserved.

Influence of myectomy, ileal valve, and ileal reservoir on the ecology of the ileum

Fecal bacteriology, fecal volatile fatty acids, and ileal mucosal morphology were studied in dogs after ileoanal anastomosis alone, ileoanal anastomosis and myectomy, ileoanal anastomosis and myectomy with ileoileal valve, and ileoanal anastomosis with duplicated (J) ileal reservoir. The ratio of anaerobes to aerobes was significantly less in stool from dogs which had undergone ileoanal anastomosis compared with each of the other three groups (P<0.01). The numbers of streptococci and clostridia both were significantly less in stool from dogs with ileoanal anastomosis alone than in any other group. The concentrations of fecal acetic and propionic acids were significantly less in dogs with ileoanal anastomosis alone than in any other group (P<0.05), but there were no significant differences in the concentrations of fecal butyric or valeric acids. The severity of mucosal inflammation and degree of villous atrophy were more marked in the ileum of J reservoirs (P<0.01), and the percentage of stool retained after defecation was greater (P<0.05) in dogs with J reservoirs than in any other group. Therefore, the use of myectomy resulted in significant changes in the ecology of the distal ileum although changes typical of pouchitis were seen only in dogs with J reservoirs.

Preservation of ileocecal junction and entire anal canal in surgery for ulcerative colitis-A «two-sphincter» operation

Disruption of the terminal ileum and excision of the ileocecal junction during restorative proctocolectomy and formation of a pelvic ileal reservoir may lead to abnormalities of motility, transit, and absorption. We therefore preserved this portion of the gastrointestinal tract in 12 patients who underwent restorative proctocolectomy for ulcerative colitis. In each patient, the entire anal sphincter was preserved without mucosal stripping: the two sphincters were connected by a single loop of ileum without any reservoir. After median follow-up of 12 months, the functional results were similar to those seen with conventional pelvic ileal reservoirs and superior to the results of mucosal protectomy and straight endoanal ileoanal anastomosis. This operation may be an alternative to standard restorative proctocolectomy for patients with ulcerative colitis.