An analysis on 87 cases (54 with familial polyposis and 33 with ulcerative colitis on whom one of the authors (J.U.) has performed ileoanal anastomosis in Tokyo and Hyogo revealed a steady and remarkable improvement of their functional results. The evolutional modifications of the authors operative technique and the current operative technique are described and illustrated in detail. The anorectal mucosa was stripped out with the forceps coagulation technique through the anal canal in the prone jackknife position. The J-shaped ileal pouch, mostly with bilateral blood supplies, was directly anastomosed to the anal sphincteric apparatus, which was excluded by a loop ileostomy for 3 months. For colitis, total colectomy and abdominal ileostomy with open rectal exclusion in principle precede the above operations (the three-staged radical surgery for colitis without a permanent ileostomy).
SirOf two reports concerning intraoperative testing of colorectal anastomoses, Beard et al. (Br .I Surg 1990; 77: 1095-7) described the effectiveness of air testing using a sigmoidoscope, while Pitchard et al. (Br J Surg 1990; 77: 1105) did air testing using a bladder syringe which might be misleading for low colorectal anastomoses using the double stapler techniques. An intraoperative leak test is performed to determine whether or not the anastomosis is air tight. However, airtight anastomoses d o not guarantee complete prevention of the postoperative leak.Recently, we have employed the urological cather with quadrant large holes (Malecot Model Drain, C. R. Bard Incorporated, Conington, Georgia, USA) for intraoperative air testing after colorectal anastomoses. A Foley catheter balloon may disrupt low anastomoses, but the procedure has the advantage of simplicity compared to the use of a sigmoidoscope. The advantage of sigmoidoscopy is the ability to observe the anastomoses directly. A Malecot catheter equipped with large holes has been useful and easy for not only air testing but also draining the residual faeces and for rectal washout. Furthermore, we positioned the catheter above the anal sphincter and connected it to a closed drainage system to decrease the intrarectal pressure in the first 5 days after operation. Anorectal manometry showed an increase of intrarectal pressure when flatus was passed'. Then, catheter drainage of flatus and faeces decompressed the anastomosed neorectum. Also we can perform a limited water-soluble contrast enema through the Malecot catheter before withdrawing it.Seventy-eight consecutive patients who underwent colorectal anastomoses with air testing by using the Malecot catheter have been evaluated. Six patients were found to have an air leak, added reinforcing sutures or a covering stoma. Two of them developed postoperative leakage. Three patients whose anastomoses were air tight developed postoperative leakage. We reduced the postoperative leak rate from 18 to 7 per cent by an introduction of a Malecot catheter.As Dr Pitchard described, leakage must be the result of factors other than the construction of structurally sound staple lines. We choose a Malecot catheter not only to make a sound anastomosis but also to minimize postoperative anastomotic hazard caused from intraluminal problems. It is an important concept that the surgeon should give special attention to the anastomosis.
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