Abstract
PURPOSE: The aim of this investigation was to ascertain how the length of anal canal preserved above the dentate line in stapled end-to-end ileoanal anastomosis influenced late outcome. METHODS: Two groups, high cuff group and low cuff group of nine subjects with stapled anastomosis, matched for sex, age, pouch configuration, and mean follow-up, representing the highest (median, 2.5 cm) and lowest (median, 0.7 cm) anal cuff lengths in our series, were selected. Physiologic and functional parameters were appraised preoperatively, at the time of ileostomy closure, and at 1, 3, 6, and 12 months after reestablishment of intestinal continuity. RESULTS: At one year, the drop in mean anal canal resting pressure was 13 percent in the high cuff group (not signficant) and 31 percent in the low cuff group (P <0.05); mean maximum squeezing pressure did not differ significantly from preoperative values in both groups. The mean volume of the ileal pouch was higher in the low cuff group at all insufflation pressures. The rectoanal inhibition reflex reappeared in four high cuff group patients and in none of the low cuff group patients. Mean distention pressure (cm H 2 O) and volume (ml) eliciting urge sensation were 80 and 360 in the low cuff group compared with 40 and 240 in the high cuff group (P ⩽0.05). Daytime bowel movements and night incontinence were significantly better in the low cuff group. No statistical differences were observed for night stool frequency, daytime incontinence, pad use (day and night), discrimination between gas and feces, ability to defer evacuation, and difficulty in emptying the pouch. CONCLUSION: Patients with stapled anastomoses and a low rectal cuff length, despite presenting lower anal resting pressure and absence of rectoanal inhibition reflex, had a better functional outcome in terms of continence than those with a high cuff length.
Similar content being viewed by others
References
Kmiot WA, Keighley MR. Totally stapled abdominal restorative proctocolectomy. Br J Surg 1989;76:961–4.
Hallgren T, Fasth S, Nordgren S, öresland T, Hultén L. The stapled ileal pouch-anal anastomosis. A randomized study comparing two different pouch design. Scand J Gastroenterol 1990;25:1161–8.
Heald RJ, Allen DR. Stapled ileo-anal anastomosis: a technique to avoid mucosal proctectomy in the ileal pouch operation. Br J Surg 1986;73:571–2.
Nivatvongs S. Ulcerative colitis. In: Gordon PH, Nivatvongs S, eds. Principles and practice of surgery for the colon, rectum and anus. St. Louis: Quality Medical Publishers, 1992:667–717.
Williams NS, Marzouk DE, Hallan RI, Waldron DJ. Function after ileal pouch and stapled pouch-anal anastomosis. Br J Surg 1989;76:1168–71.
Holdsworth PJ, Johnston D. Anal sensation after restorative proctocolectomy foor ulcerative colitis. Br J Surg 1988;75:993–6.
Keighley MR, Yoshioka K, Kmiot W, Heyer W. Physiological parameters influencing function in restorative proctocolectomy and ileal pouch-anal anastomosis. Br J Surg 1988;75:997–1002.
Johnston D, Holdsworth PJ, Nasmyth DG,et al. 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. Br J Surg 1987;74:940–4.
Sagar PM, Holdsworth PJ, Johnston D. Correlation betwen laboratory findings and clinical outcome after restorative proctocolectomy: serial studies in 20 patients with end-to-end pouch-anal anastomosis. Br J Surg 1991;78:67–70.
Wexner SD, James K, Jagelman DG. The doublestapled ileal reservoir and ileoanal anastomosis: a prospective review of sphincter function and clinical outcome. Dis Colon Rectum 1991;34:487–4.
Seow-Choen F, Tsunoda A, Nicholls RJ. Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy. Br J Surg 1991;78:430–4.
öresland T, Fasth S, Nordgren S, Hallgren T, Hultén L. A prospective randomized comparison of two different pelvic pouch design. Scand J Gastroenterol 1990;25:986–96.
Hallgren T, Fasth S, Nordgren S, öresland T, Hallsberg L, Hulten L. Manovolumetric characteristics and functional results in three different pelvic pouch designs. Int J Colorectal Dis 1989;4:156–60.
Hultén L. Kock pouch ileoanal anastomosis. Rob & Smith's operative surgery: surgery of the colon, rectum and anus. 5th ed. Butterwork-Heinemann Ltd., 1993.
Hultén L, öresland T. Alternatives to the permanent ileostomy: the ileoanal pouch. Coloproctology 1985;20:995–1000.
öresland T, Fasth S, Nordgren S, Hultén L. The clinical and functional outcome in restorative proctocolectomy. A prospective study in 100 patients. Int J Colorectal Dis 1989;4:50–6.
öresland T, Fasth S, Nordgren S, Akervall S, Hultén L. Pouch size: the important functional determinant after restorative proctocolectomy. Br J Surg 1990;77:265–9.
öresland T, Fasth S, Akervall S, Nordgren S, Hultén L. Manovolumetric and sensory characteristics of the ileoanal J-pouch compared with healthy rectum. Br J Surg 1990;77:803–6.
Hultén L, Fasth S, öresland T. Pelvic pouch—physiology vs. function. In: Nicholls J, Mortensen DB, eds. Restorative proctocolectomy. Oxford: Blackwell Scientific Publications, 1993.
åkervall S, Fasth S, Nordgren S, öresland T, Hultén L. Manovolumetry: a new method for investigation of anorectal function. Gut 1988;29:614–23.
Taylor BM, Beart RW, Dozois RR, Kelly KA, Wolff BG, Ilstrup DM. The endorectal ileal pouch-anal anastomosis: current clinical results. Dis Colon Rectum 1984;27:347–50.
Pemberton JH, Phillips SF, Ready RR, Zinsmeister AR, Beahrs OH. Quality of life after Brooke ileoswtomy and ileal pouch-anal anastomosis. Ann Surg 1989;209:620–8.
Scott NA, Pemberton JH, Barkel DC, Wolff BG. Anal and ileal pouch manometric measurements before ileostomy closure are related to functional outcome after ileal pouch-anal anastomosis. Br J Surg 1989;76:613–6.
Becker JM. Anal sphincter function after colectomy, mucosal proctectomy and endorectal ileoanal pullthrough. Arch Surg 1984;119:526–31.
Lindquist K. Anal manometry with microtransducer technique before and after restorative proctocolectomy: sphincter function and clinical correlation. Dis Colon Rectum 1990;33:91–8.
Sharp FR, Bell GA, Seal AM, Atkinson KG. Investigation of the anal sphincter before and after restorative proctocolectomy. Am J Surg 1987;153:469–72.
Nasmyth DG, Johnston D, Godwin PG, Dixon MF, Smith A, Williams NS. Factors influencing bowel function after ileal pouch-anal anastomosis. Br J Surg 1986;73:469–73.
O'Connell P, Stryker S, Metcalf A, Pemberton J, Kelly K. Anal canal pressure and motility after ileoanal anastomosis. Surg Gynecol Obstet 1988;166:47–54.
Keighley MR. Abdominal mucosectomy reduces the incidence of soiling and sphincter damage after restorative proctocolectomy and J-pouch. Dis Colon Rectum 1987;30:386–90.
Miller R, Bartolo DC, Orrom WJ, Mortensen NJ, Roe AM, Cervero F. Improvement of anal sensation with preservation of the anal transitional zone after ileoanal anastomosis for ulcerative colitis. Dis Colon Rectum 1990;33:414–8.
Duthie HL, Bennett RC. The relation of sensation in the anal canal to the functional anal sphincter: a possible factor in anal continence. Gut 1963;4:179–82.
Martin LW, Thomas AM, Fischer JE. The critical level for preservation of continence in ileoanal anastomosis. J Pediatr Surg 1985;20:664–7.
Holdsworth PJ, Johnston D. Use of the end-to-end anastomosis without mucosal stripping diminishes morbidity and time in hospital after restorative proctocolectomy. Br J Surg 1988;75:1232.
Hallgren T, Fasth S, Delbro D, Nordgren S, öresland T, Hultén L. Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy. Br J Surg 1993;80:631–5.
Stryker SJ, Kelly KA, Phillips SF, Dozois RR, Beart RW. Anal and neorectal function after ileal pouchanal anastomosis. Ann Surg 1986;203:55–60.
Grant D, Cohen Z, McHugh S, McLeod R, Stern H. Restorative proctocolectomy: clinical results and manometric finding with long and short rectal cuff. Dis Colon Rectum 1986;29:27–32.
Carlstedt A, Fasth S, Hultén L, Nordgren S. The sympathetic innervation of the internal anal sphincter and rectum in the cat. Acta Physiol Scand 1988;133:423–31.
Pescatori M, Parks AG. The sphincteric and sensory components of preserved continence after ileoanal reservoir. Surg Gynecol Obstet 1984;158:517–21.
Neal DE, Williams NS, Johnston D. Rectal, bladder and sexual function after mucosal proctectomy with and without a pelvic reservoir for colitis and polyposis. Br J Surg 1982;69:599–604.
Emblem R, Erichsen A, Mörkrid L, Ganes T, Stien R, Bergan A. Failed ileoanal anastomoses: correlation between clinical findings and anal canal neurophysiologic and histologic examinations. Scand J Gastroenterol 1989;24:623–31.
O'Connell PR, Pemberton JH, Brown ML, Kelly KA. Determinants of stool frequency after ileal pouchanal anastomosis. Am J Surg 1987;153:157–64.
Nicholls RJ, Pezim ME. Restorative proctocolectomy with ileal reservoir for ulcerative colitis and familial adenomatous polyposis: a comparison of three reservoir designs. Br J Surg 1985;72:470–4.
Taylor BM, Cranley B, Kelly KA, Phillips SF, Beart RW, Dozois RR. A clinico-physiological comparison of ileal pouch-anal and straight ileoanal anastomoses. Ann Surg 1983;198:462–8.
Hatakeyama K, Yamai K, Muto T. Evaluation of ileal W pouch-anal anastomosis for restorative proctocolectomy. Int J Colorectal Dis 1989;4:150–5.
Thomas PE, Taylor TV. Pelvic pouch procedures. Oxford: Butterworth-Heineman, 1991:60.
Lubowski DZ, Nicholls RJ, Swash M, Jordan MJ. Neural control of internal anal sphincter function. Br J Surg 1987;74:668–70.
Nagasaki A, Ikeda K, Sumitomo K. Rectoanal reflex induced by H2O thermal stimulation. Dis Colon Rectum 1989;32:765–8.
Lane R, Parks A. Function of the anal sphincters following colo-anal anastomosis. Br J Surg 1977;64:596–9.
Author information
Authors and Affiliations
Additional information
Supported by grants from the Swedish Institute of Stockholm, the Swedish Medical Research Council (17x-03117), and Göteborgs läkarsällskap, Göteborg, Sweden.
Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.
About this article
Cite this article
Annibali, R., öresland, T. & Hultén, L. Does the level of stapled ileoanal anastomosis influence physiologic and functional outcome?. Dis Colon Rectum 37, 321–329 (1994). https://doi.org/10.1007/BF02053591
Issue Date:
DOI: https://doi.org/10.1007/BF02053591