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The S ileal pouch-anal anastomosis

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Abstract

In order to determine the results with the S ileal pouch-anal anastomosis, 116 consecutive patients who had undergone total abdominal colectomy with rectal mucosectomy and endorectal ileal pouch-anal anastomosis were assessed following ileostomy closure. In 11 patients (9.5%) pouch removal and/or conversion to permanent ileostomy was necessary because of Crohn's disease (3), pelvic sepsis (3), pouchitis (2), incontinence (2), or perineal fistula (1). Although no postoperative mortality was experienced, one or more complications was experienced in 87 patients. These consisted mainly of small bowel obstruction in 35%, pouchitis in 22%, anastomotic stricture in 14%, pelvic sepsis in 9.5%, and perianal abscess or fistula in 5%. Laparotomy was required in 29% of patients mostly for resolution of small bowel obstruction. Follow-up in the remaining 105 patients ranged from 5 to 67 months with a mean of 28 months following ileostomy closure. Stool frequency was 6.6 bowel movements per day and 1.4 bowel movements per night. Eighty-nine percent evacuated their pouches spontaneously, and 61% did not require the use of medication for bowel movement regulation. Major daytime incontinence occurred in 4%, while 15% reported nocturnal incontinence. Minor incontinence was experienced by 30% and 48% during daytime and nighttime, respectively. Despite a myriad of complications, 96% of patients unhesitatingly stated that they would undergo the procedure again so that they could avoid a permanent stoma. We conclude that restorative proctocolectomy utilizing the ileal S pouch-anal anastomosis is an acceptable procedure that should be considered as a viable choice in the treatment of chronic ulcerative colitis and familial polyposis requiring surgical intervention.

Résumé

Dans le but de déterminer les résultats obtenus par l'anastomose entre une poche iléale en S et l'anus, une série de 116 patients qui ont subi une colectomie totale avec exérèse de la muqueuse endo-rectale et constitution d'une anastomose entre la poche iléale et l'anus ont été étudiés après fermeture de l'iléostomie provisoire. Chez 11 (9.5%) d'entre eux l'ablation du réservoir et/ou la conversion en iléostomie permanente a été nécessaire en raison des faits suivants: maladie de Crohn (3), infection pelvienne (3), inflammation de la poche (2), incontinence (2), fistule périnéale (1). Si aucun cas de mortalité opératoire n'a été à déplorer, des complications se sont manifestées chez 87 opérés. Elles ont consisté principalement en occlusion iléale (35%), inflammation de la poche (22%), sténose au niveau de l'anastomose (14%), infection pelvienne (9.5%), abcès périnéal ou fistule périnéale (5%). Une laparotomie fut nécessaire dans 29% des cas principalement pour traiter l'obstruction du grêle. Le contrôle post-opératoire de 105 opérés après fermeture de l'iléostomie provisoire s'étend de 5 à 67 mois avec une moyenne de 28 mois. La fréquence des selles diurnes fut de 6.6, celle des selles nocturnes de 1.4. L'évacuation spontanée fut observée dans 89% des cas et il ne fut pas nécessaire d'employer de régulateur de la mobilité intestinale dans 61% des cas. Une incontinence diurne moyenne fut observée dans 4% des cas et une incontinence nocturne dans 15% des cas. Une incontinence mineure fut enregistrée dans 30% et 48% des cas au cours respectivement du jour et de la nuit. Malgré de nombreuses complications 96% des opérés ont manifesté sans réserve le désir de se prêter à la même intervention pour éviter une iléostomie permanente. On peut conclure de ces faits que la protocolectomie utilisant la poche en S anastomosée à l'anus est une méthode acceptable qui doit être prise en considération pour traiter la colite ulcéreuse chronique et la polypose familiale relevant de l'intervention chirurgicale.

Resumen

Con el propósito de determinar los resultados con la anastomosis entre la bolsa ileal en S y el ano, se estudiaron 116 pacientes consecutivos sometidos a colectomía abdominal total con mucosectomía rectal y anastomosis endorrectal bolsa ileal-ano, una vez efectuado el cierre de la ileostomía. Once pacientes (9.5%) requirieron resección de la bolsa y/o conversión a ileostomía permanente debido a enfermedad de Crohn (3), sepsis pélvica (3), “bolsitis” (2), incontinencia (2), y fístula perineal (1). Aunque no se registró mortalidad postoperatoria, se presentaron una o más complicaciones en 87 pacientes. Estas representaron principalmente obstrucción intestinal en 35%, “bolsitis” en 22%, estenosis de la anastomosis en 14%, sepsis pélvica en 9.5%, y absceso perianal o fístula en 5%. La laparotomía fue necesaria en 29% de pacientes, principalmente para solucionar obstrucción intestinal. El seguimiento de los restantes 105 pacientes osciló entre 5 y 67 meses con un promedio de 28 meses después del cierre de la ileostomía. La frecuenica de la defecación fue de 6.6 movimientos intestinales diurnos y 1.4 nocturnos. Ochenta y nueve por ciento evacuaron sus bolsas en forma espontánea, y 61% no requirieron medicamentos para la regulación de sus movimientos intestinales. Incontinencia fecal diurna mayor se presentó en 4% de los pacientes, en tanto que 15% informaron incontinencia nocturna. Incontinencia menor diurna fue informada por 30% y nocturna por 48%. A pesar de una miriada de complicaciones, 96% de pacientes informaron en forma indudable que volverían a someterse al procedimiento con el fín de evitar un estoma permanente. Nuestra conclusión es que la proctocolectomía restauradora utilizando la anastomosis entre una bolsa ileal en S y el ano es un procedimiento aceptable que debe ser considerado como una escogencia viable en el tratamiento de la colitis ulcerosa crónica y de la poliposis familiar que requieren intervención quirúrgica.

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Vasilevsky, CA., Rothenberger, D.A. & Goldberg, S.M. The S ileal pouch-anal anastomosis. World J. Surg. 11, 742–750 (1987). https://doi.org/10.1007/BF01656597

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