Ileoanal pouch operation: long-term outcome with or without diverting ileostomy.

HYPOTHESIS: Avoiding a diverting ileostomy does not influence the long-term overall morbidity and functional outcome of patients after ileoanal pouch operation (IAP). DESIGN: All patients undergoing IAP were prospectively entered into a database, and those undergoing operation from October 1, 1989, through January 31, 1996, were contacted by mail questionnaire. SETTING: Tertiary referral center. PATIENTS: One hundred thirty unselected sequential patients. INTERVENTIONS: The IAP was completed by a stapled method without diverting ileostomy, provided the patient agreed, and there were no other complicating factors. MAIN OUTCOME MEASURES: Need for reoperation, fecal leakage, pouch frequency, ability to defer evacuation, pouchitis, and overall quality of life. RESULTS: Of 102 patients (78.5%) who initially underwent IAP without diverting ileostomy, 10 (9.8%) developed an anastomotic leak and required a diverting ileostomy. Additional surgery was required in 12 (9.2%) of the 130 patients for bowel obstruction and in 3 (2.3%) for pouch excision. Two patients died of unrelated causes, leaving 125 functioning pouches (96.2%). Questionnaires were completed in 111 (88.8%) of the 125; 75 patients (67.6%) reported perfect continence for gas and stool, 10 patients (9.0%), regular nighttime leakage, and 24 patients (21.6%), occasional fecal leakage. Pouch evacuation frequency (+/-SD) per 24 hours was 7.8+/-2.4 (range, 4-12), and 95.5% of patients could defer pouch evacuation. Of the 111 patients, 42.3% reported pouchitis, with 7.2% receiving long-term antibiotic therapy. Of the patients, 74.8% reported total satisfaction, and 84.7% regarded themselves as being in perfect health. CONCLUSION: Long-term outcome after IAP remains favorable with or without diverting ileostomy.

Outcome of early surgical complications following ileoanal pouch operation without diverting ileostomy.

BACKGROUND: Many surgeons use a diverting ileostomy routinely following ileoanal pouch operation because they fear that complications may lead to permanent unsatisfactory pouch function or even death. We report the outcome of early surgical complications when ileoanal pouch operation is performed without a diverting ileostomy. We performed 74 consecutive ileoanal pouch operations since ileoanal pouch operations since October 1989 using a transition-zone-sparing stapled J pouch method. RESULTS: Of the 74 patients, 68 (92%) underwent the operation without a diverting ileostomy. Five of the 68 patients (7.4%) required reoperation within 30 days of operation. Pouch excision was necessary in 2 patients (3%) for reasons not resulting from omitting the diverting ileostomy, and they now have excellent pouch function. CONCLUSION: Patients who required early reoperation and placement of a temporary diverting ileostomy did not suffer long-term consequences. The fear that early surgical complications following ileoanal pouch operation without diverting ileostomy are permanently detrimental is unjustified.

Factors favoring continence, the avoidance of a diverting ileostomy and small intestinal conservation in the ileoanal pouch operation.

Ileoanal pouch operation was performed upon 38 consecutive patients with ulcerative colitis (36 patients) or familial polyposis (two patients). Mucosectomy was avoided by rectal mobilization to the dentate line and eversion and stapling of the exteriorized anorectal junction with the dentate line in view. An 8 centimeter J pouch was stapled to the anorectal junction. A diverting ileostomy was not used in 34 of the 38 patients. Physicians independent of the operation evaluated patients postoperatively. Eighty-four percent of the patients did not experience any problems with incontinence or nocturnal spotting at one month postoperatively. No incontinence or nocturnal spotting was seen in any patient by one year postoperatively, with the exception of one patient with chronic pouchitis who had occasional nocturnal spotting that continues to improve. The average number of bowel movements per 24 hours was five at 12 months postoperatively, despite the small pouch. The mean distance from the dentate line to the ileoanal anastomosis was 0.9 +/- 0.5 centimeter (range of zero to 2 centimeters).

Comparative efficacy of parenteral histamine (H2)-antagonists in acid suppression for the prevention of stress ulceration.

Stress-related mucosal damage is related to a high intraluminal hydrogen ion concentration, a low intramural pH value, and a breakdown of the gastric mucosal barrier. Because the presence of gastric acid is required for stress-related mucosal damage to occur, therapy aimed at increasing intraluminal pH values has often been used as prophylaxis against complications. The amount of acid suppression required for adequate prophylaxis of gastrointestinal bleeding from stress-related mucosal damage has not been determined, but many investigators use a target gastric pH level of 3.5 to 4.0. When intravenous histamine (H2)-receptor antagonists are given in bolus dosing regimens to critically ill patients, fluctuations in gastric pH values are often observed, as might be expected. However, recent studies with primed continuous infusion of cimetidine in critically ill patients have demonstrated that consistent elevation of gastric pH to 4.0 may be attained with this regimen. Studies with continuous infusions of ranitidine are less conclusive; little information is available on famotidine.

Isolated external iliac artery aneurysm secondary to cystic medial necrosis.

The computed tomographic and angiographic findings of an isolated external iliac artery aneurysm secondary to cystic medial necrosis in a patient without Marfan's disease are demonstrated. A review of the differential diagnosis and surgical treatment of iliac artery aneurysms is presented. The dramatic surgical sequelae in this patient underscore the importance of preoperative consideration of this rare diagnosis.

Primary sphincter repair in anorectal trauma.

Two patients who sustained severe anorectal trauma from "fist fornication" were treated by irrigation, colostomy, drainage, antibiotics, and primary repair of the rectum and anal sphincters without complications. Both had complete return of continence. Primary sphincter repair is advocated for these and similar anorectal injuries.

Duodenojejunostomy for the pancreaticobiliary complications of duodenal diverticulum.

A Roux-en-Y duodenojejunostomy has been used as treatment of pancreaticobiliary disease associated with duodenal diverticula in three patients with good results. This approach removes the diverticulum from the food stream, thereby solving the problems of recurrent cholangitis and pancreatitis caused by food stasis in the diverticulum, without having to excise the diverticulum or perform a gastrectomy and vagotomy.

The superficial radial nerve: techniques for evaluation.

Several methods for obtaining radial nerve sensory responses have been compared. A technique for antidromic latency measurement over a fixed distance most consistently produced responses which were easy to obtain, reliable and well tolerated by the subjects.