The ileo neorectal anastomosis: an experimental study on development of the surgical technique and theoretical background

Abstract

Objective The keystones of surgical treatment of ulcerative colitis and familial adenomatous polyposis are resection of the diseased colon with either an ileostomy or restoration of oro-anal continuity with an ileo-anal pouch. The ileo pouch anal anastomosis however, has a 15±35% pouch-related complication rate, 10% failure rate and is accompanied by an unpredictable functional outcome. In order to reduce these unfavourable rates and to improve functional results an alternative surgical technique, the ileo neorectal anastomosis (INRA), was developed experimentally. Materials and methodsIn an experimental study 12 Yorkshire-Dutch landpigs had a subtotal colectomy and rectal mucosectomy. Subsequently a vascularized ileal mucosa sling was created and transposed on to the denuded rectal muscular cuff in eight. In another four animals a non-vascularized mucosa sling was transposed. The covering ileostomy was closed after 3 weeks. Repeated endoscopies, histological examinations of mucosal biopsies and rectal compliance measurements were carried out to evaluate the functional result of the neorectum. ResultsThe surgical procedure of the INRA was technically successful in this animal study. Repeated endoscopy and histology showed complete ileal mucosa ingrowth in the neorectum without severe ®brosis in the group of animals with a vascularized sling. At follow up after 1 year no colonic metaplasia had occurred. Measurements of the neorectal reservoirs in the group of animals with a vascularized INRA procedure showed a median`maximum tolerated volume' of 338 ml (range 300±410 ml). ConclusionThe INRA is technically feasible and reproducible. The histologically proven survival of the vascularized ileal mucosa and development of a compliant neorectal reservoir make the INRA an interesting alternative restorative procedure. Avoidance of the pouchrelated complications of the ileo pouch anal anastomosis by this procedure might herald a new era of restorative surgery.

The ileo neo‐rectal anastomosis in patients with familial adenomatous polyposis: a prospective case series with long‐term follow up

“…Functional results at this stage were comparable to those reported in the literature for IPAA [5]. [3,6] (Fig. 1).…”

“…All patients gave written informed consent. The INRA was performed as described by Van Laarhoven [3,6] (Fig. 1).…”

“…In a select group of patients, restorative surgery, such as IPAA, is an option and is dependent on age, phenotype and presence and number of rectal adenomas. In an attempt to reduce the procedure‐related complications of pelvic dissection during IPAA, ileoneo‐rectal anastomosis (INRA) has been developed [2,3]. Using INRA a pelvic dissection is avoided, the colonic and rectal mucosal linings are removed and oro‐anal continuity is restored by constructing an ileal mucosal transposition into the rectum (Fig.…”

Evaluation of long‐term function, complications, quality of life and health status after restorative proctocolectomy with ileo neo rectal and with ileal pouch anal anastomosis for ulcerative colitis

“…RPC was performed by three surgeons in the Radboud University Nijmegen Medical Centre and INRA was carried out by two dedicated surgeons from the University Medical Centre Utrecht and one from the St Elisabeth Hospital Tilburg. INRA was performed after colectomy as described by van Laarhoven et al [7,10]. RPC was performed as described by Nicholls and Pezim [16].…”

“…Mean maximum resting and squeeze pressure in the four quadrants of the anal canal was calculated [20,21]. Neorectal compliance was assessed by balloon manometry [7,10,11]. dysfunction, fistulae, pouchitis, anal strictures, diet limitations and the prolonged use of antidiarrhoeal medication were all recorded.…”