Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: A pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis

Abstract

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.

Randomized Prospective Trial Comparing Ileal Pouch-Anal Anastomosis Performed by Excising the Anal Mucosa to Ileal Pouch-Anal Anastomosis Performed by Preserving the Anal Mucosa

“…23 Principally because up to 50% of patients after endorectal mucosa resection and handsewn IPAA are incontinent of stools at night, a new operation was introduced: double-stapled ileal pouch-anal anastomoSiS. 4 In this operation, the ileal pouch is stapled to the top of the anal canal, thus preserving the anal transition zone (ATZ). The hypothesis was that because the ATZ was innervated richly,5 by saving the ATZ, sensation would be improved and the frequency of incontinence lessened.…”

Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis.

“…Ulcerative colitis 14 15 12 14 Indeterminate colitis 0 0 3 0 Crohn's disease 0 2 0 0 Previous colectomy 1 3 3 5 One stage RP 7 5 5 6 Eversion of anorectum 10 14 9 Ltd, Welwyn Garden City, UK) to a chart recorder (5041 Ormed Ltd). 8 Threshold electrosensitivity of the mucosa of the anal canal was measured in the upper, mid and lower anal canal (as determined by anal manometry) by means of a bipolar constant current stimulator probe lubricated with a solution of KY Jelly (Johnson and Johnson, Slough, UK) and normal saline in equal quantities.' 0 l 1 Capacity and compliance of the reservoir were measured by means of a latex balloon 7.5 cm in length, which was attached to a 14 FG catheter, similar to that used for anal manometry.…”

The perfect pelvic pouch--what makes the difference?

“…Nevertheless many patients enjoy excellent function after restorative proctocolectomy, and it has been shown previously that good function after restorative proctocolectomy depends on the presence both of a capacious and compliant pelvic ileal reservoir1 2 and of an anal sphincter that is strong and sensitive. [3][4][5] The aim of this study was to determine the optimum functional characteristics of the ileal reservoir, and what combination of motor, sensory, and reflex properties in the anal sphincter complement the reservoir.…”