Ten years experience of one-stage restorative proctocolectomy for ulcerative colitis.

BACKGROUND: Ileal-pouch anal anastomosis has an established role in the treatment of ulcerative colitis. Controversy exists regarding the routine use of a diverting ileostomy. The aim of this study was to review the clinical and functional outcome of patients undergoing restorative proctocolectomy in the absence of a diverting ileostomy (one-stage). MATERIALS AND METHODS: Between 1990 and 1999, 87 patients with ulcerative colitis underwent a one-stage restorative proctocolectomy. The median age at the time of operation was 34 years (range 12-64 years) and median follow-up was 36 months (range 24-144 months). The clinical notes were reviewed retrospectively. RESULTS: The median in-patient stay was 15 days (range 9-36). There were no post-operative deaths. The complication rate within 30 days of surgery approximated to 40%. The median daytime pouch evacuation rate was 5. Only 13% of patients had to empty their pouch at night on a regular basis. Pelvic sepsis secondary to anastomotic leakage was the most commonly encountered problem, occurring in 15 patients. Small bowel obstruction was encountered in ten patients. One pouch required excision for a recurrent pouch-vaginal fistula. CONCLUSION: Despite refinements in the surgical technique, restorative proctocolectomy is associated with significant morbidity. For a selected group of patients undergoing an ileo-anal anastomosis, a defunctioning ileostomy may be avoided.

Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation.

PURPOSE: The aim of this study was to determine the long-term symptomatic and anatomic results of rectocele repair for impaired defecation. METHODS: All 26 females operated on during a five-year period in one hospital were reviewed in clinic. Follow-up was available on 22 patients after a median of 27 (range, 5-54) months. Interview, anorectal physiological testing, and evacuation proctography were performed preoperatively and postoperatively. Fifteen patients had a transperineal repair and seven patients had a transanal repair. RESULTS: Sixteen (73 percent) patients felt improved. A feeling of incomplete emptying (19 vs. 10, preoperative vs. postoperative; P = 0.02) and the need to use digital assistance vaginally (13 vs. 6; P = 0.07) were both reduced by surgery, the former being improved significantly more often after transperineal repair. The rectocele width and area were reduced by both types of surgery; however, the rectocele diameter was greater than 2 cm in 16 patients preoperatively and 10 patients postoperatively. There was no significant difference between patients who did or did not feel improved by surgery in the percentage reduction in rectocele width (22 vs. 18 percent; P = 0.95), the percentage reduction in rectocele area (65 vs. 62 percent; P = 0.95), or a rectocele width of more than 2 cm (44 vs. 50 percent; P = 0.80), did vs. did not feel improved, respectively. CONCLUSION: Operative repair symptomatically improves a majority of patients with impaired defecation associated with a large rectocele, but the improvement probably relates at least in part to factors other than the dimensions of the rectocele.

Intra-abdominal and pelvic abscess in Crohn's disease: results of noninvasive and surgical management.

BACKGROUND: Intra-abdominal and pelvic abscesses occur in 10-30 per cent of patients with Crohn's disease. The aim of this study was to establish the clinical characteristics and outcome of patients admitted over a 4-year period with an abdominal or pelvic abscess secondary to Crohn's disease. METHODS: Patients with Crohn's disease-related intra-abdominal or pelvic abscess were identified from a prospectively collected database, comprising all admissions between 1991 and 1994. Medical records were reviewed retrospectively and data gathered regarding management and outcome. RESULTS: Thirty-six patients were identified with Crohn's disease-related abscess, of whom 15 were considered for initial percutaneous drainage. Drainage was technically possible in eight of these patients: it failed in four, gave good long-term results in two, and was followed by recurrence after 3 years in one and by later surgery unrelated to the abscess in one. Twenty-eight patients underwent surgery, with only four requiring a stoma. Complications occurred in 12 patients. At 3 months, 22 of the 36 patients were in remission. CONCLUSION: Crohn's intra-abdominal abscesses are associated with a high morbidity rate. Selected cases can be drained percutaneously, without adding to the morbidity, and sometimes resulting in abscess resolution.

Internal anal sphincter repair.

The results of repair to the internal and sphincter alone has been evaluated in five patients with persistent anal incontinence following surgery which affected the internal anal sphincter. All had passive incontinence for solid or liquid stool. Symptoms, anorectal manometry, and anal endosonography were evaluated before and after surgery. After surgery three patients felt improved but had still persistent symptoms, and no patients achieved full continence. Three patients showed an increased maximal and resting pressure, but only one of them was within the normal range. Post operatively, all the anal ultrasound scans showed a persistent internal sphincter defect, and two showed an unsuspected external anal sphincter defect. Although some patients felt symptomatically improved, the overall clinical, manometric and radiological findings after internal and sphincter repair were disappointing.

Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature.

Pneumatosis coli is a rare condition characterised by multiple gas-filled cysts within the bowel wall. We present 25 cases treated over the past 30 years. The patients' mean age was 59 years: 15 were female. Presenting symptoms included diarrhoea (n = 17), mucus discharge (n = 17), rectal bleeding (n = 15) and constipation (n = 12). Pneumatosis usually affected the left colon (96%), and diagnosis was by sigmoidoscopy and biopsy in 18 cases (72%). Pneumatosis coli was associated with psychiatric disorders (36%), chronic lung disease (20%) and colitis (12%). A redundant sigmoid colon was observed in 80% of cases on contrast radiology. Five patients had mucosal pseudolipomatosis on histological examination. Histological and immunohistochemical review indicated that the cysts were lined by cells of macrophage/monocyte phenotype and that many similar mononuclear cells were present in the adjacent submucosa and overlying mucosa. Treatment with antidiarrhoeals and anti-inflammatory drugs in 14 patients resulted in improvement in 9 cases (64%). Oxygen therapy (n = 9) always alleviated symptoms. There was a high recurrence rate (50-78%), but with further courses of therapy lasting remission was achieved in five patients. Two patients underwent colectomy. The associations of pneumatosis coli with psychiatric disorders and mucosal pseudolipomatosis are new and of possible pathogenetic significance. A novel pathogenetic mechanism is suggested to explain the association of pneumatosis coli and chronic respiratory disorders. A model of pneumatosis coli linking some of the apparently disparate pathogenetic theories is proposed.

Stenosis of the pouch anal anastomosis following restorative proctocolectomy.

PURPOSE: To compare the incidence of stenosis after hand-sewn and stapled ileoanal anastomosis. Stenosis of the ileoanal anastomosis occurs in 5-16% of patients undergoing a restorative proctocolectomy but the incidence using a stapled technique is unknown. METHODS: Between 1976 and 1990, 266 patients underwent restorative proctocolectomy or proctectomy at one hospital. In two hundred and eighteen the anastomosis was hand sewn and stapled in 48 (single 33; double 15). RESULTS: Stenosis occurred in 31 (14.2%) of the hand-sewn and in 19 (39.6%) of the stapled anastomoses. This difference was highly significant (P < 0.001). Stenosis was not related to the size of the staple head used or to the stapling technique. There was no relationship between the development of stenosis and pelvic sepsis. Twenty six (hand-sewn 16, stapled 10) of the 48 patients with stenosis needed dilatation under general anaesthetic. CONCLUSION: Stapled anastomoses may result in a high incidence of anastomotic stenosis.

Prognostic factors in surgery for local recurrence of rectal cancer.

Fifty-five patients had resection of locally recurrent rectal cancer. Fourteen patients (25 per cent) had distant metastases, which were resected concurrently in six (11 per cent). Thirty-three patients (60 per cent) had preoperative (one patient) or postoperative (32) external beam radiotherapy (45-60 Gy). The 5-year survival rate was 18 per cent with a median survival of 24 months. The median symptom-free interval was 24 months. At a median follow-up of 28 months 53 per cent of patients had a second local recurrence and 24 per cent metastases only. Treatment complications occurred in 12 patients (22 per cent), three (5 per cent) of whom died 3-10 months after operation. Variables that were significantly related with longer survival and palliation were the radical nature of the operation, the absence of severe symptoms (such as pain, obstruction or sepsis), a recurrent tumour diameter of less than 5 cm measured on the resected specimen and a normal carcinoembryonic antigen level after reoperation. A Cox regression model showed that recurrent tumour diameter was the only independent prognostic variable. Surgery for local recurrence achieved local control in 47 per cent of patients with a low morbidity and mortality rate.

New grade-related prognostic variable for rectal cancer.

The effect of microacinar growth patterns on survival after radical surgery for rectal cancer was assessed in 138 consecutive patients. All had Dukes and Jass staging and a median follow-up of 95 (range 11-180) months. Tumour acini were classified according to size (microacinar, 28; macroacinar, 110). Patients with microacinar tumours had a significantly reduced 5-year survival rate compared with those with macroacinar lesions (43 and 68 per cent respectively, P = 0.004). When examined in the presence of other histological factors, acinar size had independent prognostic value (relative risk 2.37, P = 0.006). This was true even when the Dukes and Jass classifications were included in the model (relative risk 2.08, P = 0.02 and 1.95, P = 0.03 respectively). Histological classification of rectal tumours into microacinar and macroacinar types adds prognostic value to the Dukes and Jass classifications and may be a more objective criterion than conventional histological grading.

The first 10 years' experience of restorative proctocolectomy for ulcerative colitis.

Between 1976 and 1985, 110 patients had restorative proctocolectomy or proctectomy for ulcerative colitis and 103 were followed up until death or February 1992. There was one postoperative and one late death related to surgery. The cumulative probability of pouch failure was 12% at five years: half of the failures occurred within one year. The commonest reasons were perianal/pelvic sepsis and probable Crohn's disease. The cumulative probability of readmission, excluding that for ileostomy closure, was 68% at five years. There were 152 operations carried out during readmissions. These included 44 laparotomies. Function was assessed in 80 patients at a mean of 99.3 months after ileostomy closure. For 66 patients with spontaneous evacuation, average minimum diurnal frequency was 3.8, maximum 4.9, with 35 evacuating at night. One patient experienced major continence problems, 30 had minor leaks, and 49 were completely continent. Postoperatively, five patients gave birth to nine babies, four had renal stones, two myasthenia gravis, and two severe anaemia: seven had pre or postoperative thyroid dysfunction.

Surgery for ulcerative colitis in the era of the pouch: the St Mark's Hospital experience.

The choice of operation for ulcerative colitis among 422 patients having all their surgery at one hospital between 1976 (the year of the first restorative proctocolectomy) and 1990, was reviewed. The 15 year period was divided into three quinquennia (1976-80, 1981-85, 1986-90). Elective surgery was performed in 316 patients with one operative death. The proportions of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia were 36/60, 17/60, 4/60; 29/111, 30/111, 35/111; 30/145, 17/145, 75/145. Of 106 urgent operations with three postoperative deaths, 12 had a conventional proctocolectomy and 86 a colectomy with ileostomy and preservation of the rectum. Of 85 survivors of the latter there were two late deaths and in 13 no further surgery had been done at the time of this assessment. In the remaining 70 having subsequent surgery the proportion of conventional proctocolectomy, colectomy with ileorectal anastomosis, and restorative proctocolectomy for the three quinquennia respectively were 19/27, 4/27, 14/27; 11/21, 2/21, 8/21; 5/22, 4/22, 13/22. Of the 76 patients having colectomy with ileorectal anastomosis 12 (16%) no longer had a functioning rectum at the end of 1990. Of the 153 patients having an ileoanal pouch procedure, 11 (7%) no longer had, a functioning anus. The study showed an increase in the numbers of patients having elective surgery for ulcerative colitis during the three quinquennia. It also showed a rise of restorative over conventional proctocolectomy with diminution in elective colectomy with ileorectal anastomosis in the last five year period.

Coloanal sleeve anastomosis in the treatment of diffuse cavernous haemangioma of the rectum: long-term results.

Diffuse cavernous haemangioma of the rectum is an unusual lesion. In 1971 Parks and co-workers described resection and coloanal sleeve anastomosis as an alternative operation in the treatment of this rare malformation. The clinical presentation, diagnosis and long-term results of patients with this condition managed by such a surgical technique are described. Resection and coloanal sleeve anastomosis offers major advantages such as a lower risk of intraoperative bleeding, no risk of damaging the pelvic nerves, sparing of continence and avoidance of a permanent colostomy. It should therefore be considered the treatment of choice for this uncommon condition.

Civilian and war injuries of the perineum and anal sphincters.

Patients with pelvic and perineal non-obstetric trauma were studied to determine the clinical outcome in relation to faecal continence. Between 1980 and 1992, 65 patients were referred for post-traumatic assessment of the anal sphincters and continence mechanism. All patients were continent before trauma. Using clinical examination, manometry, concentric-needle electromyography and most recently anal endosonography, external sphincter defects were identified in 56 patients, of whom 52 underwent overlapping sphincter repair. The external sphincter was considered to be intact in nine patients. At a median follow-up of 12 months a good result (continence grades 1 and 2) was achieved in 36 of 52 patients and a poor outcome (continence grades 3 and 4) in ten; six patients were lost to follow-up. A good clinical result was associated with a significant increase in resting pressure (median increase 15 cmH2O; P = 0.017) and squeeze pressure (median increase 35 cmH2O; P = 0.001). At postoperative assessment three patients with a poor outcome were shown to have a second unsuspected contralateral sphincter defect that had not been repaired. Physiological and endosonographic investigation combined with late surgical repair leads to a good outcome in most patients with traumatic sphincter damage.

Overlapping anal sphincter repair for faecal incontinence due to sphincter trauma: five year follow-up functional results.

Disruption of the anal sphincter results from obstetric injury, ano-rectal operations or external trauma. Obstetric or surgical division of the sphincteric mechanism may not be immediately apparent and the clinical presentation of incontinence may occur several years later [1, 2]. Reconstruction of the sphincter using a fascial sling or direct end-to-end repair of the disrupted sphincter result in a high failure rate. Failure after direct end-to-end repair is usually caused by break down of the suture line owing to retraction of the muscle ends [3]. Parks advocated an overlapping repair [4] in which the disrupted ends of the sphincter were mobilised and wrapped around each other. This paper reports the results of overlapping sphincter repair for faecal incontinence resulting from trauma, after a 5 year follow-up period.

Lower gastrointestinal malignancy in Crohn's disease.

An increased incidence of carcinoma of the small bowel and colon has been described in patients with Crohn's disease. Tumours arising in the rectum and anus are reported less often. Between 1940 and 1992, of some 2500 patients with Crohn's disease seen at this hospital, 15 are known to have developed carcinoma of the lower gastrointestinal tract. Malignancy occurred in the colon in two patients, in the upper two thirds of rectum in one, in the lower third of rectum in seven, and in the anus in five. The 12 patients with carcinoma arising in the anus or lower rectum had longstanding severe anorectal Crohn's disease, which included a stricture in four, fistula in four, proctitis in one, abscess in two, and enlarged anal skin tags in one. The development of malignancy in patients with Crohn's disease may apply particularly to those with chronic complicated anorectal disease.

Ileal pouch arthritis.

The association between arthritis and intestinal inflammation is well established, but the pathogenesis of the inflammatory joint disease remains speculative. We report six patients who developed a polyarthritis following restorative proctocolectomy with an ileal pouch-anal anastomosis (IPAA) for extensive ulcerative colitis between 1983 and 1990. Six patients were identified with no complaint of joint symptoms before surgery. The average time to onset of arthritis following surgery was 8 months (1 week-yr). The typical features were of an acute symmetrical polyarthritis involving the peripheral and axial skeleton. Early morning stiffness was pronounced in two and minimal in the rest. Three patients were treated with a course of prednisolone and remain in remission (1-4 yr). We believe that this is a novel form of arthritis clearly linked to pouch surgery which may provide important clues to the role of gastrointestinal antigens in rheumatic diseases.

Reappraisal of radical local excision for carcinoma of the rectum.

Outcome in all 167 patients treated by radical local excision for rectal carcinoma between 1948 and 1984 at St Mark's Hospital was assessed in terms of the original tumour differentiation except for 15 patients with incomplete follow-up or ungraded tumours. Fifty-six of the 152 patients had low-grade tumours, with one death from carcinoma in this group. Of 81 patients with average-grade tumours, ten died from carcinoma of the rectum: two after early reoperation and eight following recurrence. Six of 15 patients with high-grade tumours underwent early reoperation and three of these died from carcinoma. Among the nine patients who did not undergo early reoperation there were three related deaths (two from carcinoma, one after rectal excision for recurrence). Local excision remains a valid therapy for suitable patients with low-grade tumours but is not recommended for those with average-grade lesions. The necessity for early reoperation in patients with high-grade tumours is questioned.

Pouch-vaginal fistula.

Between January 1976 and June 1991, 161 women underwent restorative proctocolectomy. Seventeen (10.6 per cent) developed pouch-vaginal fistula. There was no difference in the incidence of inflammatory (15 of 141; 10.6 per cent) and non-inflammatory (two of 20; 10 per cent) disease, the severity of colitis or the number of stages in the operation. In 15 patients the fistula involved the ileoanal anastomosis; in two it had possibly occurred at the dentate line. There was no significant difference in the proportion of hand-sewn (ten of 120; 8.3 per cent) and stapled (seven of 41; 17 per cent) ileoanal anastomosis. Of the 17 women, six had pelvic sepsis in the immediate postoperative period and five had an anastomotic complication. There was no case of Crohn's disease. Three patients developed a pouch-vaginal fistula before closure of the ileostomy. The remaining 14 fistulas occurred a median of 7 (range 1-144) months after closure. Five further patients were referred from elsewhere to give a total of 22 for analysis of treatment and outcome. The fistula developed before ileostomy closure in five patients (group 1) and after closure in 17 (group 2). Following treatment, six fistulas had healed with five patients still undergoing treatment. In group 1, three of the five fistulas healed, whereas in group 2 only three of the 17 healed. Eight patients required excision of the pouch. The prognosis appears to be worse when pouch-vaginal fistula occurs after ileostomy closure. The optimal management is not yet established.