Patients undergoing colorectal surgery who required a defunctioning stoma were randomly allocated to receive either a loop ileostomy (n = 23) or transverse loop colostomy (n = 24). Assessment was made during construction, immediately postoperatively, during the period of outpatient supervision and before and after stoma closure. The ileostomy was associated with significantly less odour than the colostomy (P less than 0.01) and required significantly less appliance changes (P less than 0.05). Furthermore eleven patients (58 per cent) with a colostomy experienced three or more problems with stoma management compared with only three patients (18 per cent) with an ileostomy (P less than 0.05). Wound infection was also significantly more common after closure of the colostomy compared with the ileostomy. Both types of stoma were demonstrated objectively to defunction the distal bowel almost completely. These results indicate that a loop ileostomy is the procedure of first choice when a stoma is needed to defunction the distal colorectum.

Seventeen patients were studied 3-31 months (median 6.4 months) after mucosal proctectomy and ileal pouch-anal anastomosis for ulcerative colitis (n = 15) or adenomatous polyposis (n = 2). Seven had a triplicated pouch, and ten a duplicated pouch. Clinical bowel function was determined by detailed questionnaire, and correlations sought between clinical end-points such as frequency of defaecation, urgency of defaecation and continence, and the results of laboratory investigations, comprising anal manometry, capacity and compliance of the pouch, completeness of emptying, faecal bacteriology and mucosal inflammation. Frequency of defaecation was found to be inversely correlated with both the capacity (rs = -0.66, P less than 0.01) and the compliance (rs = -0.53, P less than 0.05) of the pouch. Patients who could postpone defaecation for greater than 30 min had higher anal squeeze pressures (P less than 0.05) than patients who had greater urgency of defaecation. Patients with perfect anal continence had higher resting anal pressure (P less than 0.05) and emptied the pouch more completely (P less than 0.01) than patients who experienced minor leakage. The faecal flora of the pouches showed a greater predominance of anaerobes (P less than 0.01) and increased numbers of bacteroides (P less than 0.01) compared with the faecal flora of ileostomies, but the changes in the flora did not correlate with any aspect of bowel function. The best clinical results (i.e. perfect continence, low frequency of defaecation and little urgency) were associated with high anal pressure and with large volume, high compliance and complete emptying of the pouch. The completeness of emptying was similar for both designs of pouch, but the capacity and compliance of triplicated pouches were greater than the capacity and compliance of duplicated J pouches (P less than 0.05), and this was associated with a better clinical result in the triplicated pouches.

Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure and low RAP has been found to correlate with minor leakage of faeces or mucus. Our hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA: each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH2O (60-116 cmH2O) to 70 cmH2O (25-104 cmH2O, P less than 0.01), whereas after MP + PTA maximal RAP decreased from 85 cmH2O (70-125 cmH2O) to 40 cmH2O (22-80 cmH2O, P less than 0.003). RAP after EEA was significantly greater than RAP after MP + PTA (P less than 0.001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the pre-operative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than pre-operative pressure (P less than 0.001) and the sphincteric high pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA 58 per cent of patients experienced minor faecal leakage (P less than 0.01). These findings suggest that the entire anal canal should be kept intact in the course of conservative proctocolectomy for ulcerative colitis.

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The case of a 54 year old man with Fabry's disease and extensive jejunal and colonic diverticulosis causing colonic stricture is presented. Histological examination of the resected colon revealed evidence of ceramide trihexose deposition in the myenteric nerve plexus. Colonic involvement in Fabry's disease has not been reported before.

Among 39 consecutive patients who underwent colectomy, mucosal proctectomy and ileo-anal anastomosis, a triplicated pelvic ileal pouch was constructed in 17, and a duplicated pouch in 22 patients. There was no mortality, but complications such as anastomotic dehiscence and pelvic sepsis led to removal of the pouch in seven patients (18 per cent). The functioning of the pouch and anal sphincter was assessed in 31 patients 6 months, and in 22 patients 12 months after closure of the diverting ileostomy. By 6 months, all patients were either completely continent or experienced only minor leakage and defaecation could be deferred for more than 15 min by 81 per cent of patients and flatus distinguished from faeces by 90 per cent of patients. No significant differences between triplicated and duplicated pouches were discernible at 6 months. At 12 months defaecation was significantly less frequent (P less than 0.05) in patients with triplicated pouches (median, 5 times in 24 h) than in patients with duplicated pouches (7 times in 24 h). All patients with triplicated pouches and all except one with duplicated pouches were able to defaecate spontaneously, without needing to intubate the reservoir. Thus, provided the early postoperative problems can be overcome, most patients achieve good anal function after mucosal proctectomy combined with a pelvic ileal reservoir. No evidence was found in this study that the functional results of duplicated pouches were superior to those of triplicated pouches; in fact, the triplicated pouches proved to be slightly superior.

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