Radiology of ileal pouch-anal anastomosis: normal findings, examination pitfalls, and complications

Ileal pouch-anal anastomosis (IPAA) is a procedure in which an ileal reservoir is constructed after total colectomy and anastomosed to the anus. IPAA is a well-established option for patients who require surgery for chronic ulcerative colitis or familial adenomatous polyposis. Although excellent functional results can be achieved with IPAA, the procedure is associated with an appreciable number of complications, including small bowel obstruction, pouch fistula, anastomotic separation, anastomotic leakage, pelvic infection and abscess, stricture, and pouchitis. However, most of these complications do not require surgical intervention and can be managed with aggressive medical treatment and delay of ileostomy closure. Radiography of the IPAA pouch is routinely performed before closure of the diverting ileostomy to evaluate the integrity of the pouch and anastomosis. Such radiography can demonstrate many of the complications of IPAA, thus allowing identification of patients who may require intervention or delay before closure of the ileostomy.     

Typical complications and their control after restorative proctocolectomy

The overall rate of complications after ileal pouch-anal anastomosis is 60%. This rate, however, includes complications such as bowel-obstruction and hernias. Pouch-related complications occur after ileal pouch-anal anastomosis with a frequency of 15-25%. In an analysis of the recent literature the main risk factors are: tension of the ileal pouch-anal anastomosis, anastomotic leakage, lack of protective ileostomy, preoperatively undiagnosed Crohn's disease and the experience of the surgeon. We classified pouch related-complications into (1) surgical complications (leakage, bleeding, pelvic sepsis, fistulas); (2) technical problems (long S-pouch spout, rectal cuff stenosis, etc.); (3) functional problems (anal sphincter insufficiency, night incontinence, hypermotility, evacuation disorders); (4) pouchitis; (5) pouch neoplasias. Pathogenesis, diagnostic features, and medical and surgical therapy are discussed in detail. In our own series of 11 pouch-redo operations we had 6 pouch fistulas (3 related to Crohn's disease, 3 postoperative fistulas), 3 wrongly constructed pouches, 1 chronic pouchitis and 1 long S-pouch spout. In 3 cases the pouch had to be excised completely. Two patients remained with a permanent ileostomy. In 6 patients the pouch could be preserved on long term. Due to the technical complexity, the need to understand pathophysiology and the need for a differentiated diagnostic procedure, this operation should be performed only in specialised centers.     

The pull-through procedure: technical factors in influencing outcome, with emphasis on pouchitis

BACKGROUND: The purpose of the study was to review those features that we believed to be critical to the successful performance of the ileal pouch-anal anastomosis, or pull-through, procedure, and specifically the complication of pouchitis. METHODS: The charts of 205 patients who successfully underwent ileal pouch-anal anastomosis procedure were reviewed. No follow-up was available in five patients; therefore, the basis of this report and its analysis was based on 200 consecutive procedures in which at least two of the three surgeons participated. Particular emphasis was placed on continence, particularly nighttime continence. The incidence of pouchitis, either a single episode or intermittent episodes, was surveyed. Particular attention was paid to the level of rectal mucosectomy and anastomosis at the top of the columns of Morgagni, thus retaining the transitional zone. RESULTS: Only 5% of patients were incontinent in the absence of pouchitis. Twenty-five patients (13%) wore a pad at night, but only nine (5%) wore a pad during the day. Of those patients with pouchitis, 6% (12) have had a single episode and 12% (23) were intermittently on medication. Therapy of pouchitis was usually carried out with ciprofloxacin 500 mg by mouth everyday or twice a day. CONCLUSIONS: Ileal pouch-anal anastomosis is an excellent procedure, provided technical details are adhered to. Satisfactory outcome with respect to nighttime continence can be achieved with rectal mucosectomy with minimal manipulation and retaining the transitional epithelium, performing the pouch anastomosis at the top of the columns of Morgagni. The incidence of pouchitis is disappointing but need not be inhibiting of either patients or carrying out this life-saving procedure in patients with ulcerative colitis and familial polyposis.     

Neutrophil signaling alteration: an adverse inflammatory response after burn shock

BACKGROUND: Perinuclear antineutrophil cytoplasmic antibodies occur frequently in adult patients with chronic pouchitis after colectomy and ileal pouch-anal anastomosis for ulcerative colitis. The purpose of the study was to determine the prevalence of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in children and adolescents who undergo colectomy and ileal pouch-anal anastomosis for ulcerative colitis and familial adenomatous polyposis. METHODS: Five groups of children and adolescents (age, <20 years) were studied, with the following histories: acute pouchitis and history of ulcerative colitis; chronic pouchitis and history of ulcerative colitis; pouchitis with Crohn's disease features and a history of ulcerative colitis; no pouchitis and a history of ulcerative colitis; and familial adenomatous polyposis, with or without pouchitis. Antineutrophil cytoplasmic antibody levels and titers were detected in postoperative sera by enzyme-linked immunosorbent assay, and positive results were subtyped by indirect immunofluorescence. RESULTS: The frequency of perinuclear antineutrophil cytoplasmic antibodies and cytoplasmic antineutrophil cytoplasmic antibody in patients with a history of ulcerative colitis were 67% and 15%, compared with a 0% presence in patients with familial adenomatous polyposis (p < 0.001). There was no significant correlation between the frequency of perinuclear antineutrophil cytoplasmic antibodies and ulcerative colitis patient subgroups (patients with and without pouchitis, 66% and 75%). Similarly, there was no significant correlation between the frequency of cytoplasmic antineutrophil cytoplasmic antibodies among ulcerative colitis patient subgroups (patients with and without pouchitis, 19% and 8%). The frequency of cytoplasmic antineutrophil cytoplasmic antibody in patients with Crohn's disease features (50%), was increased, but this difference was not significant. CONCLUSIONS: There is a high frequency of perinuclear antineutrophil cytoplasmic antibodies in children and adolescents who undergo ileal pouch-anal anastomosis for ulcerative colitis, whether or not they have pouchitis. The frequency of cytoplasmic antineutrophil cytoplasmic antibody is lower in this patient population. Additional studies will be required to determine whether the presence of cytoplasmic antineutrophil cytoplasmic antibody is associated with the postoperative development of features of Crohn's disease.     

Trace elements in egg contents and egg shells of slider turtles (Trachemys scripta) from the Savannah River Site

OBJECTIVES: Stricture of the vesico-urethral anastomosis is a well-known complication after radical prostatectomy. Dilatation, stricture incision or resection have been proposed for endoscopic treatment. METHODS: In a retrospective study of 340 patients with prostatic cancer who underwent a radical retropubic prostatectomy from 1988 until 1996, we looked at the incidence of anastomotic strictures. RESULTS: An anastomotic stricture was found in 24 cases (7%) requiring endoscopic treatment. Based on prospective X-ray studies, we were able to show that the site of stricture is located below the bladder neck musculature in most cases well above the distal urethral sphincter and pelvic floor. No continence problems were encountered following structure resection in a follow-up of 12-72 months determined by a questionnaire and pad test. CONCLUSION: The transurethral resection of anastomotic stricture allows for a rather generous tissue resection, which is preferable to incision or dilatation in our hands.     

Mapping protein-ligand interactions by footprinting, a radical idea

PURPOSE: This study investigated the functional significance of perineal complications after ileal pouch-anal anastomosis. METHODS: Review of a prospective registry of 628 patients was undertaken. Bowel function was assessed by detailed functional questionnaire. Statistical analyses were performed using chi-squared and Fisher's exact probability tests. RESULTS: Of 628 patients, 153 (24.4 percent) had 171 perineal complications. The 277 control patients had no complications. Complications included 66 (10.5 percent) anastomotic strictures, 28 (4.5 percent) anastomotic separations, 36 (5.7 percent) pouch fistulas, 41 (6.5 percent) episodes of pelvic sepsis, and 18 (2.9 percent) patients with multiple complications. After these complications were addressed, the pouch failure rate was low (10 percent); in 90 percent of patients, the pouch could be salvaged. Most pouch failures were the result of pouch fistulas, and most occurred in patients ultimately diagnosed with Crohn's disease. Functional results after cure of these perineal complications revealed no significant functional differences between control patients and those cured of anastomotic separations, anastomotic strictures, and pouch fistulas. Only a few minor differences were demonstrated in function after an episode of pelvic sepsis. The major deterioration in function occurred after treatment for multiple perineal complications. CONCLUSIONS: An appreciable number of perineal complications occur after ileal pouch-anal anastomosis. Pouch-perineal fistulas are associated with the highest pouch failure rate. The majority of these fistulas occur in patients ultimately diagnosed with Crohn's disease or indeterminate colitis. Although there is no substitute for good technique and sound clinical judgment in the success of ileal pouch-anal anastomosis, if perineal complications are successfully treated, functional outcome is equivalent to that in patients without perineal complications.     

Anastomotic stenoses correlated with the use of mechanical staplers in the surgery of esophageal cancer

From 1990 to 1995, 187 patients underwent esophagectomy and esophagogastrostomy with the anastomosis performed inside the chest using a circular stapler. Twenty-three patients (12.3%) developed an anastomotic stricture. The incidence of anastomotic stricture was inversely related to the diameter of the stapler. Also concomitant cardiovascular diseases, morpho-functional disorders of the tubulized stomach (possible related to duodeno-gastric reflux) and neoadjuvant chemotherapy were recognized as significant risks factors. Endoscopic dilations were safe and effective in the treatment of anastomotic strictures.     

A new technique of esophagogastrostomy above the aortic arch--covering and suspending of the anastomotic area with mediastinal pleura flap

The postoperative anastomotic leakage is the most severe complication and the principal cause of death after resection of esophageal carcinoma. Especially, anastomosis above the aortic arch is accompanied by high incidence of anastomotic leakage usually with fatal prognosis. The authors improved the conventional method of anastomosis by using a mediastinal pleura flap to cover and suspend the anastomotic area with excellent result. From January of 1990 to April of 1995, 210 patients with esophageal carcinoma were so treated. No anastomotic leakage or stricture developed. Only one patient died of extensive myocardial infarction with an overall mortality of 0.47%. The major merit of this procedure was that the mediastinal pleura flap could cover the area of anastomosis and sustain the dragging force acting on this area, providing a better condition for the anastomosis to heal and thus reducing the possibility of anastomotic leakage.     

Ileal pouches: adaptation and inflammation

Ileal pouch-anal anastomosis (IPAA) has become the operation of choice following proctocolectomy for ulcerative colitis (UC) and familial adenomatous polyposis. Functioning ileal pouch mucosa undergoes histological changes resembling the colon (colonic metaplasia). The possible role of stasis and luminal factors--bile acids, short-chain fatty acids and bacteria--are discussed. It seems likely that colonic metaplasia is an adaptive response to the new luminal environment in IPAA. Inflammation in the ileal reservoir ('pouchitis') is the most significant late complication in IPAA. It occurs in 20-30% of patients and is virtually confined to those with prior UC. The clinical picture in pouchitis is highly variable; however, it can be easily categorized into three groups. Nevertheless, in most cases it is likely to represent recurrent UC in the ileal pouch. Current treatments and possible preventative strategies for pouchitis have been outlined.     

New treatment for ileal pouch-anal or coloanal anastomotic stenosis

Persistent anastomotic stricture following ileal pouch-anal or coloanal anastomoses can be treated by transanal resection using a stapler or a more complex procedure, such as transanal pouch advancement with neoanastomosis. We propose an easier and faster technique, which does not require any particular device. Its long-term functional results are satisfactory in most patients.     

Carinal resection for primary lung cancer--with special attention to a modified double-barrel method

Carinal resection for primary lung cancer was clinically evaluated. Carinal resection was performed in 18 patients, 17 males and one female, with a mean age of 64 years. Nine patients underwent carinal reconstruction and the other 9 sleeve or wedge pneumonectomy. The carinal reconstruction was of the montage type in one patient, the one-stoma type in 2, and the modified double-barrel method in 6. The modified double-barrel method is a technique that we developed by adding bronchial end-to-side anastomosis to the tracheobronchial end-to-end anastomotic site. A pedicled intercostal muscle flap was used for covering the anastomotic site. The postoperative respiratory complications after carinal reconstruction were anastomosis failure in 4 patients (pin-hole in 3) and respiratory failure in 2. However, no anastomosis stricture occurred, and recovery was satisfactory. There were no respiratory complications after pneumonectomy. One patient had renal failure before surgery and died of multiple organ failure 23 days after a montage type carinal reconstruction. The other 17 patients did well and could be discharged from the hospital and the overall mortality rate was 5.6%. No anastomosis stricture occurred in the modified double-barrel method. By carinal reconstruction covering of the anastomotic site is mandatory to prevent fatal postoperative complications.     

Transformations of ileo-rectal anastomosis into ileo-anal anastomosis in hemorrhagic rectocolitis. Indications and results

In order to precise the indications and results of this procedure, we assessed 11 cases of transformation of ileorectal anastomosis (IRA) to ileal pouch-anal anastomosis (IPAA) in ulcerative colitis (UC). These 5 men and 6 women had undergone IRA at a mean age of 31 years, 33 months after the diagnosis of UC (range 3-120). Four of these IRA, excluded by an ileostomy, had never been in function: the cause was severe persistent proctitis in 2 cases and anastomotic leakage and peritonitis in 2 cases. The other 7 IRA had been in function during a mean period of 25 months (range 6-45) and were reoperated because of anal sepsis (1 case), low rectal stenosis (1 case), disabling proctitis (4 cases) and rectal dysplasia (1 case). No patient had specific pathologic signs of Crohn's disease. The 11 IPAA were complicated by pelvic sepsis in 3 cases; surgical drainage succeeded in 1 case, but the 2 others needed pouch excision and terminal ileostomy. The diagnosis of Crohn's disease was eventually made in these 2 patients. The 9 patients with functioning IPAA, at a mean follow-up of 40 months (range 12-60), had 5.2 stools per 24 h (range 2-12), 5 patients had no nocturnal stooling, and 6 had a perfect continence. One patient had disabling chronic pouchitis. In conclusion, proctectomy with IPAA is always feasible when a previous IRA for UC had failed or offers poor results, but should be rejected in case of anal involvement, as that may suggest Crohn's disease. This procedure is followed by similar functional results than after primary IPAA.     

The value of early postoperative oesophagography following repair of oesophageal atresia

The aim of the study was to examine the relationship between anastomotic leaks and the development of symptomatic anastomotic strictures after primary repair of oesophageal atresia (OA) with or without tracheo-oesophageal fistula (TOF) and the prognostic value of the anastomotic appearance on postoperative oesophagography. The records and X-ray films of 49 patients with OA with or without TOF admitted between January 1990 and June 1995 were reviewed retrospectively. Of these, 37 had a primary repair (34 immediate and 3 delayed) and a postoperative contrast swallow was done between day 5 and day 30 (median day 7). Radiological leaks were documented. In addition, the maximum transverse diameters of the upper pouch and anastomotic region and the length of the anastomotic narrow segment were measured; the ratio of upper-pouch diameter to that of the anastomosis was calculated (anastomotic index, AI). The need for dilatation of symptomatic anastomotic strictures and for repeat dilatation as a separate episode were documented. Of the 37 patients, 4 developed an anastomotic leak (11%), 3 radiological and 1 clinical. A symptomatic stricture occurred in 55% of patients. There was no correlation between a leak and later development of a symptomatic stricture, although the small number of patients with leaks precluded definite conclusions. No radiological leak progressed to a clinical leak. There was no correlation between the AI or the length of the anastomotic narrow segment and the need for dilatation, the need for repeat dilatation, or the number of dilatations. In this study, the presence of a leak, the AI, and the length of the narrow segment on early postoperative contrast swallow did not correlate with the later development of a symptomatic stricture. A radiological leak was of no clinical significance. Since major leaks are apparent clinically, an early routine contrast study did not influence management and is not necessary.     

A stereologic study on the influence of stent tube pressure on bilio-intestinal anastomotic scar formation

Biliary tract injury results often in biliary scar stricture causing obstructive jaundice and biliary cirrhosis. Choledocho-jejunostomy with tube stent is the routine to prevent anastomotic stenosis, but how long the stent tube should be in place is controversial and little is known on the influence of the stent tube on anastomotic scar formation. In canine experimental models, bili-intestinal scar was sampled 3 weeks, 3, 6, 9 and 12 months after anastomosis for ultrastructure stereologic image analysis. It was found that the internal pressure of the stent tube exerting on anastomotic stoma inhibits scar formation, and the stent tube should be remained inside the stoma for not less than 9 months.     

Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis

BACKGROUND: Anal sphincter function is increasingly preserved following rectal excision for cancer and provides a better quality of life for patients than does a permanent colostomy. However, anastomotic complications may cause considerable morbidity and mortality. This retrospective study examined the incidence of anastomotic complications following two forms of reconstruction after resection for mid-rectal cancer: colonic pouch-anal anastomosis (CPAA) and low colorectal anastomosis (LCRA). METHODS: Some 258 consecutive patients with mid-rectal cancers between 6 and 11 cm from the anal verge underwent proctectomy with mesorectal excision and either CPAA or LCRA. The incidence of clinical and radiological leaks was determined in these patients who were considered in three groups: LCRA (defunctioning stoma), LCRA (no defunctioning stoma) and CPAA (all defunctioned). RESULTS: In the LCRA group without a defunctioning stoma, a clinical leak occurred in 17.0 per cent, compared with two of 30 in the LCRA group with a defunctioning stoma. In the CPAA group a clinical leak occurred in 4.9 per cent of patients, which was not significantly different from the rate in those with a defunctioned LCRA. Patients with a non-defunctioned LCRA were more likely to suffer a clinical anastomotic leak (P=0.01), peritonitis (P=0.001) and require unscheduled reoperation (P=0.006) than those with a defunctioned LCRA and/or CPAA. CONCLUSION: The use of a protective defunctioning stoma is advocated in conjunction with LCRAs.     

Esophagogastrostomy with the EEA stapler

Esophagogastric anastomosis was performed with the EEA stapler in 31 patients who underwent esophageal resections. Anastomoses were accomplished at all levels of the thoracic and cervical esophagus by a variety of approaches. Routine barium cine-esophagograms obtained at seven days after operation failed to demonstrate an anastomotic leak in any patient. The operative mortality rate was 3% (1 of 31 patients). Technical problems occurred during the operation in three patients; in two of these an incomplete anastomosis may have resulted from the surgeon's error. All patients were able to swallow normally at the time of discharge. Late anastomotic stricture occurred in five patients, and responded to dilatation in all but one patient who had local tumor recurrence. We conclude that the EEA stapler allows rapid and reliable esophagogastric anastomosis. Successful use of the instrument requires strict attention to technical detail and awareness of possible pitfalls.     

Pouchitis: pathophysiology and treatment

Pouchitis is a potential complication after proctocolectomy and restorative ileoanal anastomosis. It is more frequent in UC than in familial polyposis. Little is known about the etiopathology of pouchitis. Risk factors include the presence of extraintestinal manifestations, primary sclerosing cholangitis, cessation of smoking, and previous course of disease. A host of pathophysiological pathways have been identified as potential mechanisms of pouchitis, which include inflammatory mediators, adhesion molecules, oxygen radical species, p-ANCA, and short-chain fatty acids. The microflora in the pouch may also be an important factor in causing inflammation. The risk of developing cancer in cases of pouchitis has not been established as clearly as in those of UC. Particular attention should be paid to patients who have remaining anorectal mucosa after pouch construction. Experience in the treatment of chronic relapsing and chronic refractory pouchitis is limited. The continuation of conventional anti-inflammatory treatment is successful only in a small percentage of patients. New biological response-modifying therapies which target novel immunoregulatory molecules in IBD will also have impact on the systemic and topical treatment of pouchitis.     

Management of desmoid tumors in patients after ileal pouch-anal anastomosis for familial adenomatous polyposis

PURPOSE: The aim of this study was to review the management of desmoid tumors in patients who have undergone ileal pouch-anal anastomosis for familial adenomatous polyposis and their outcome. METHODS: A retrospective review of case notes was undertaken in a series of 196 patients with familial adenomatous polyposis who had had an ileal pouch-anal anastomosis. Eleven patients were identified in whom desmoid tumor had developed (4 male; median age, 30 (range, 16-43) years). RESULTS: Desmoid tumors developed in the abdominal wall alone in 4 of 11 patients. Three enlarging tumors were resected with no subsequent recurrence. No patient received adjuvant treatment and pouch function remained stable at a median follow-up of eight years. Mesenteric desmoid tumors developed in seven patients; the pouch has been excised in two because of ischemia; two other patients have had defunctioning stomas created because of slow progression of their desmoid tumors. One patient had a single-lumen pouch excised and a new S-pouch inserted, with no subsequent recurrence of the desmoid tumor, and in two patients the mesenteric desmoid tumor has remained unchanged. All of these patients received long-term Clinoril (sulindac, Merck & Co., Inc., West Point, PA). Although there has been no significant deterioration in pouch function in patients in whom the pouch remains in situ, the pouch function was significantly worse compared with a control group of patients after ileal pouch-anal anastomosis for familial adenomatous polyposis in whom desmoid tumors did not develop. CONCLUSION: Desmoid tumors developed in 5.6 percent of 196 patients after ileal pouch-anal anastomosis for familial adenomatous polyposis. No patient with abdominal-wall desmoid tumor had a recurrence after local excision. By contrast, mesenteric desmoid tumors eventually resulted in pouch failure in four of seven affected patients.     

Colorectal surgery using a biofragmentable anastomotic ring

To compare the efficacy of the biofragmentable anastomotic ring (Valtrac-BAR, Davis and Geck, Medical Device Division, Danbury, CT, USA) with conventional anastomotic techniques, 30 patients who underwent colorectal surgery from August 1993 to March 1995 were retrospectively studied. The use of the BAR was also compared with conventional techniques including hand-sewn sutures in 30 patients and an end-to-end anastomosis (EEA) stapler in 24 patients. There were 17 men and 13 women in the BAR group with ages ranging from 37 to 80 years, 18 men and 12 women in the hand-sewn group with ages ranging from 41 to 82 years and 14 men and 10 women in the EEA group with ages ranging from 38 to 72 years. Surgical indications included: 25 colon cancers and five rectal cancers in the BAR group; 27 colon cancers and three rectal cancers in the hand-sewn group; and six colon cancers and 18 rectal cancers in the EEA group. There was no conversion to other anastomotic methods. Most of the patients tolerated a low-residual diet from the fifth post-operative day. No clinical leakage or stricture was noted. Only seven patients were aware of the passage of BAR fragments. The mean hospital stay was 14.1 days. There were no significant differences among these techniques in the return of bowel function, the incidence of surgical complications, including anastomotic leakage, or the length of hospitalization. BAR anastomosis was more time efficient than conventional techniques. Our results confirmed that BAR was an ideal sutureless alternative for anastomosis in colorectal surgery.     

Similarities between pleuropulmonary blastoma and Askin tumor

AIM: The purpose of the study was to determine the risk of postoperative complications and the functional outcome after a hand-sewn ileal pouch-anal anastomosis (IPAA) for ulcerative colitis using a single J-shaped pouch design. METHODS: Preoperative function, operative morbidity and long-term functional outcome were assessed prospectively in 1310 patients who underwent IPAA between 1981 and 1994 for ulcerative colitis. RESULTS: Three patients died after operation. Postoperative pelvic sepsis rates decreased from 7 per cent in 1981-1985 to 3 per cent in 1991-1994 (P = 0.02). After mean follow-up of 6.5 (range 2-15) years, the mean number of stools was 5 per day and 1 per night. Frequent daytime and nighttime incontinence occurred in 7 and 12 per cent of patients respectively, and did not change over a 10-year period. The cumulative probability of suffering at least one episode of 'clinical' pouchitis was 18 and 48 per cent at 1 and 10 years and the cumulative probability of pouch failure at 1 and 10 years was 2 and 9 per cent respectively. CONCLUSION: These results indicate that increased experience decreases the risk of pouch-related complications and that with time the functional results remain stable, but the failure rate increases.