S. Fasth

The clinical and functional outcome after restorative proctocolectomy. A prospective study in 100 patients

One hundred consecutive patients treated by restorative proctocolectomy with construction of an ileo-anal anastomosis and a J-shaped (n=90) or an S-shaped ileal reservoir were studied prospectively to evaluate postoperative complications and functional outcome and to search for factors that might influence results. There were no deaths. Postoperative complications requiring surgery were pelvic sepsis (3 patients), pouch-related fistula (2), peritonitis following ileostomy closure (3) and small bowel obstruction (6), with an overall relaparotomy rate of 14%. The cumulative risk of pouchitis was 30% at 2 years. The average stool frequency decreased gradually, stabilising at about five evacuations/24 h after 1 year. At that time 9% of patients still had ≥7 day-time evacuations and 40% had night evacuations (>1/week). These parameters did not improve further with time. Mucous soiling, a frequent problem initially, also diminished with time, occurring in 30% of patients at 1 year. At 2 years, however, this mucous leak occurred in only 20%, suggesting that improvement of continence can be expected to occur even beyond one year. Despite defects in function patient satisfaction was generally excellent. So far only three patients have preferred conversion to an ileostomy. To establish which factors might influence the functional results a specially designed scoring system, combining all functional variables, was used. It was shown that results deteriorated with increasing age and that elderly women tended to have a poorer result than elderly men. Sex, previous parity or postoperative complications appeared not to affect the functional outcome. Male sexual disturbances occurred in 8%. Three had erectile problems and one loss of ejaculation. Female sexual dysfunction was frequent; dyspareunia and/or leaks during intercourse occurred in about 30%. These results confirm that resorative proctocolectomy with construction of an ileal pouch-anal anastomosis can be performed safely with a reasonable complication rate. Although patient satisfaction is often high, the functional results are not perfect, however, and further trials are in progress in this unit to determine whether results can be improved by altering the techniques for fashioning the pouch.

Sympathetic nervous influence on the internal anal sphincter and rectum in man

The effect of sympathetic nerve block and efferent stimulation of the sympathetic nerves on anorectal motility was studied in 21 patients undergoing operation for rectal carcinoma. Anal pressure and rectal volume were simultaneously recorded before and after epidural anaesthesia and during nerve stimulation. Efferent electrical stimulation of the presacral hypogastric nerves (HGN) elicited a contraction of the internal anal sphincter (IAS) in 13 out of 15 patients. The contraction was preceded by a relaxation in seven patients. In the rectum stimulation of the HGN caused variable responses. A weak contraction was the most frequent response. Efferent stimulation of the periarterial lumbar colonic nerves (LCN) elicited a clear-cut contraction of the IAS, while rectal motor responses were only occasionally observed. Epidural anaesthesia encompassing the thoraco-lumbar region (EDA), when used to block the sympathetic discharge to the IAS and the rectum, caused a reduction of anal pressure (28±11%) and an increased rectal tone. The results imply that the human IAS receives a sympathetic excitatory innervation via both the HGN and the LCN. Furthermore, it appears that the HGN convey inhibitory fibres to the IAS. The rectal responses to EDA and sympathetic nerve stimulation also indicate the presence of both excitatory and inhibitory neurones in the sympathetic nerve supply to the rectum in man.

Long-term ileostomy complications in patients with ulcerative colitis and Crohn's disease

Ileostomy complications in 203 patients operated on with proctocolectomy and ileostomy for ulcerative colitis and Crohns disease were investigated prospectively. The patients were examined at regular intervals by interview and thorough examination of the stoma. Stomal dysfunction was carefully assessed and patients presenting with surgical complications were admitted for reconstruction. The crude rate of ileostomy complications necessitating reconstruction was 34% and significantly higher in patients with Crohns disease compared with patients with ulcerative colitis. The cumulative rate of surgical revision after 8 years was 75% in the former group and 44% in the latter. Ileostomy stenosis and sliding recession were the two most common indications for reconstruction. Eighty-three per cent of the revisions were performed as local procedures, making a formal laparotomy unnecessary. Causative factors such as surgical technique, length of concomittant ileal resection and postoperative weight gain were analysed for possible influence on the rate of reconstruction, but no significant association was identified.

The functional results after colectomy and ileorectal anastomosis for severe constipation (Arbuthnot Lane's disease) as related to rectal sensory function

Rectoanal manovolumetry during graded isobaric rectal distension was carried out in 12 women with severe constipation classified as slow transit constipation (Arbuthnot Lanes disease). The resting anal sphincter pressure, the rectoanal inhibitory reflex and the rectal capacity were all normal. While thedistension volumes required to elicit sensation of rectal filling and an urge to defaecate were within normal limits in all patients thedistension pressures required to elicit such sensations fell outside the 95% limits of variation of control subjects in 4 patients. All patients were subsequently subjected to colectomy and ileorectal anastomosis. Patients with normal rectal sensory function had a satisfactory functional result after colectomy, whereas the four patients with blunted sensation did not improve. These findings suggest that rectoanal manovolumetry with determination of the distension pressures required to elicit rectal sensation is an important preoperative measure to be used in patients with severe constipation for selection of patients suitable for colectomy and ileorectal anastomosis.

Manovolumetric characteristics and functional results in three different pelvic pouch designs

Different pouch designs and techniques for the perineal approach have been on trial in an attempt to improve results after restorative proctocolectomy. The 1-year results of two currently advocated procedures, the J-pouch and the S-pouch, were compared with the results obtained in patients with a pelvic pouch fashioned according to the folding technique used for the Kock continent ileostomy, all pouches having been constructed from equal 30 cm lengths of ileum. The maximal volume of the S- and Kock pouches at one year was 420 ml (250–570) (median and (range)) and 410 ml (244–490) respectively, while it was significantly less, 305 ml (200–445) in the J-pouch (p<0.05). The compliance of the J-pouches was also significantly lower at all distension pressures. The median day-time defaecation frequency was four and was equal in the three groups. Although there was a tendency towards a more favourable overall functional result with less soiling, and less need for night evacuations among patients with a Kock-folded pouch compared to the other pouch types these differences failed to reach statistical significance. The favourable properties of the Kock pouch, well-known also from the continent ileostomy and urostomy, suggest that its design should be considered an interesting alternative even for restorative proctocolectomy. These encouraging results have yet to be confirmed in a comparative randomized trial.

Epidural anaesthesia and postoperative colorectal motility — a possible hazard to a colorectal anastomosis

The effects of epidural anaesthesia (EDA, mepivacaine) and EDA in combination with atropine and neostigmine on postoperative intestinal motility were studied in 17 patients undergoing operation for cancer of the rectum or sigmoid colon. Motility was recorded by a volumetric technique. Epidural anaesthesia (EDA) increased motor activity in the small bowel as well as in the left colon and rectum. Phasic motility dominated in the small intestine whereas tonic and segmental contractions were recorded from the large bowel. EDA induced a powerful tonic contraction with a concomitant shortening of the rectum. This effect was inhibited by atropine. The influence of atropine/ neostigmine on left colonic motor activity was studied in six patients before and during EDA in a cross-over fashion. When administered alone, atropine/neostigmine did not cause any motility increase. Atropine/neostigmine administered during EDA, however, elicited a significant increase of motility. The increase of intestinal motor activity induced by EDA may expose a newly constructed colorectal anastomosis to undue strain in the immediate postoperative period. When EDA is used in combination with general anaesthesia, particular attention should be directed towards the use of neostigmine for reversing the effect of nondepolarizing muscle relaxants. Atropine appears under such circumstances not to protect from the excitatory effects of this drug on colorectal motility.

Postoperative complications in colorectal surgery in relation to preoperative clinical and nutritional state and postoperative nutritional treatment

The impact of the pre-operative nutritional and clinical state on post-operative morbidity and mortality is not fully known and the effect of total parenteral nutrition (TPN) on the postoperative complication rate has not been established. We have investigated the effects of postoperative TPN on the complication rate in 92 patients after major colorectal surgery for carcinoma of the large bowel or inflammatory bowel disease in a controlled, randomised study. The complication rate was analysed against seven commonly used nutritional (biochemical and anthropometric) variables and against the diagnosis, clinical inflammatory activity and presence of pre-operative septic complication. Patients were randomly allocated to postoperative TPN or conventional fluid and electrolyte support. The results show no correlation between the complication rate and the nutritional and clinical state of the patients as assessed pre-operatively. The complication rate was not significantly reduced by postoperative TPN. This study indicates that biochemical and anthropometric nutritional variables do not identify patients at risk to develop postoperative complications. The presence of pre-operative complications showed a marginal correlation with postoperative morbidity, in agreement with previous experience. The result of this study obviates the use of TPN in routine postoperative care.

The immediate and long-term effects of postoperative total parenteral nutrition on body composition

The short and long-term effects of post-operative total parenteral nutrition (TPN) on body composition were studied in a randomised series of patients undergoing major colorectal surgery. Ninety-two patients (colorectal cancer: 50, ulcerative colitis or Crohns disease: 42) were grouped according to diagnosis and clinical inflammatory activity. TPN was given for 9.7±1.1 days. The complication rate was not changed by the TPN. Nitrogen balance was studied during the first week. Body weight, total body potassium, triceps skinfold, serum albumin and body water were measured before and at intervals up to 24 weeks after the operation. Cumulative nitrogen balance in control patients at 7 days after surgery was −47.3 g. Patients given TPN balanced nitrogen intake and output (cancer patients and patients with quiescent inflammatory bowel disease, IBD) or were in positive balance (patients with active IBD). Weight loss at 1 week after surgery was less in TPN patients compared to controls and this difference remained statistically significant up to 6 months after termination of the nutritional treatment. A similar, although not statistically significant, difference was noted in total body potassium and triceps skinfold. Patients with active IBD regained pre-operative body composition earlier than cancer patients and patients with quiescent IBD. It is concluded that TPN after major colorectal surgery reduces postoperative weight loss and that this effect lasts after termination of the nutritional treatment. In the absence of increased body potassium and increased body water, we conclude that the long-term effect of TPN on body weight is most likely due to preservation of fat. Preservation of cell mass was only demonstrable at one week after surgery. The results show that weight loss continues after discharge from hospital irrespective of nutritional treatment. Patients with ongoing inflammatory activity showed a less profound catabolic response and regained pre-operative body composition earlier than patients with quiescent IBD. The normal neuro-endocrine response to major abdominal surgery includes a period of weight loss. This weight reduction is derived from loss of cell mass, fat and water [1]. The magnitude of the weight loss depends on the operative trauma, the individual patients nutritional state and the nutritional therapy in the perioperative period [2]. It has been shown that postoperative total parenteral nutrition (TPN) prevents loss of body weight and negative nitrogen balance in the first postoperative week [3–6]. It is unclear, however, whether this short-term effect on body weight and nitrogen balance lasts beyond the immediate postoperative period.The purpose of this investigation was therefore to study, prospectively and under controlled conditions, the effects of a limited course of postoperative TPN on body composition. A comparison was made between patients operated on for colo-rectal carcinoma and those operated upon for ulcerative colitis (UC) or Crohns disease (CD). It was also considered of interest to assess whether postoperative TPN alters the metabolic response to surgery differentially in patients with varying degrees of inflammatory activity.

Restoration of intestinal continuity (pelvic pouch) after previous proctocolectomy with distal mucosal proctectomy

Colectomy with full thickness proximal proctectomy and endoanal distal mucosal proctectomy may be a rational alternative to the conventional single stage proctocolectomy for ulcerative colitis. One of the great attractions of the method is that the preserved anal canal and anal sphincters may subsequently be used for restoration of intestinal continuity. Two patients are described who were both successfully treated by construction of a pelvic pouch at a second stage. This approach should be considered an alternative for patients with severe ulcerative colitis particularly those in whom preservation of the rectum is judged to be hazardous.