Factors influencing bowel function after ileal pouch–anal anastomosis

Abstract

Seventeen patients were studied 3-31 months (median 6.4 months) after mucosal proctectomy and ileal pouch-anal anastomosis for ulcerative colitis (n = 15) or adenomatous polyposis (n = 2). Seven had a triplicated pouch, and ten a duplicated pouch. Clinical bowel function was determined by detailed questionnaire, and correlations sought between clinical end-points such as frequency of defaecation, urgency of defaecation and continence, and the results of laboratory investigations, comprising anal manometry, capacity and compliance of the pouch, completeness of emptying, faecal bacteriology and mucosal inflammation. Frequency of defaecation was found to be inversely correlated with both the capacity (rs = -0.66, P less than 0.01) and the compliance (rs = -0.53, P less than 0.05) of the pouch. Patients who could postpone defaecation for greater than 30 min had higher anal squeeze pressures (P less than 0.05) than patients who had greater urgency of defaecation. Patients with perfect anal continence had higher resting anal pressure (P less than 0.05) and emptied the pouch more completely (P less than 0.01) than patients who experienced minor leakage. The faecal flora of the pouches showed a greater predominance of anaerobes (P less than 0.01) and increased numbers of bacteroides (P less than 0.01) compared with the faecal flora of ileostomies, but the changes in the flora did not correlate with any aspect of bowel function. The best clinical results (i.e. perfect continence, low frequency of defaecation and little urgency) were associated with high anal pressure and with large volume, high compliance and complete emptying of the pouch. The completeness of emptying was similar for both designs of pouch, but the capacity and compliance of triplicated pouches were greater than the capacity and compliance of duplicated J pouches (P less than 0.05), and this was associated with a better clinical result in the triplicated pouches.

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

“…Results-One year after operation, 57 patients were available for assessment: each had good anal continence, though eight experienced minor leakage of mucus, and all were able to defer defecation for more than 15 minutes. Median bowel frequency in 24 hours (IQR) in patients with J reservoirs (5 (4-7)) did not differ significantly from that of patients with W reservoirs (5 (4)(5)(6)). Likewise, bowel frequency in patients with the smaller (30 cm) reservoirs did not differ significantly from bowel frequency in patients with the larger (40 cm) reservoirs.…”

Poor Neorectal Evacuation as a Cause of Impaired Defecatory Function After Low Anterior Resection: A Study Using Scintigraphic Assessment

“…11 However, few studies on the relationship between neorectal evacuation and defecatory function after LAR have been conducted. 12,13 In the present study, scintigraphic assessment of neorectal evacuation was done in patients who underwent LAR with a straight anastomosis.…”

Pouch Surgery — The Importance of the Transitional Zone

“…The group with preservation of the anal transitional zone had a mean maximum resting pressure of 57.6±3.8 mmHg and the mucosectomy group 47.3±4 mmHg. The relationship between incontinence and low mean maximum resting pressures has been identified by other authors (3,9,14). Preservation of resting pressure is dependent upon preservation of internal anal sphincter integrity.…”

“…Preservation of resting pressure is dependent upon preservation of internal anal sphincter integrity. The internal anal sphinctcrn injured during mucosecromy due to anal dilation (3,9). The authors' obser, vation in this as:.cssment of their raticnts suppnrcs the observations made earlier (12)(13)(14).…”

“…Incontinent patients have lower maximum anal resting pressures than t hose who are continent (3,9). Maxi, mum anal resting pressures are decreased by anal retraction dunng mucosa!…”