Pembérton, John H.

Abstract Background Proctocolectomy with ileal pouch-anal anastomosis (IPAA) has been developed and refined since its introduction in the late 1970s. Nonetheless, it is a procedure associated with significant morbidity. The aim of this review was to provide a structured approach to the challenges that surgeons and physicians encounter in the management of intraoperative, postoperative and reoperative problems associated with ileoanal pouches. Methods The review was based on relevant studies identified from an electronic search of MEDLINE, Embase and PubMed databases from 1975 to April 2011. There were no language or publication year restrictions. Original references in published articles were reviewed. Results Although the majority of patients experience long-term success with an ileoanal pouch, significant morbidity surrounds IPAA. Surgical intervention is often critical to achieve optimal control of the situation. Conclusion A structured management plan will minimize the adverse consequences of the problems associated with pouches.

Abstract Background This study determined survival and recurrence rates following curative resection of rectal cancer without radiotherapy. Methods This was a retrospective review of the Mayo Clinic database of patients with rectal cancer treated with curative intent using surgery alone from 1990 to 2006. Patients who received neoadjuvant chemotherapy or radiation therapy and those who had any postoperative radiotherapy were excluded. Details were collected from the database and patient records using a protocol approved by the institutional review board. Results Some 655 consecutive patients with rectal cancer treated with curative intent using surgery alone were identified; 397 had stage I disease, 125 stage II and 133 stage III. Four hundred and nine patients underwent anterior resection (AR) and 246 abdominoperineal resection (APR). Median follow-up was 62 months. The 5-year rate of local recurrence was 4·3 per cent, disease-free survival 90·0 per cent and cancer-specific survival 91·5 per cent. Stage-specific and all-stage disease-free survival did not differ significantly between AR and APR. The 5-year cumulative local recurrence rate was lower following AR than APR (3·6 versus 5·5 per cent; P = 0·321). There were only two patients with positive margins and type of operation was not significant on multivariable analysis. Conclusion Well-performed, standardized APRs have similar local recurrence to AR. Radiation therapy may not confer much additional benefit. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Abstract The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (http://www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.

Abstract Background The aim was to evaluate outcomes in patients with ulcerative colitis complicated by primary sclerosing cholangitis (PSC) who required ileal pouch–anal anastomosis (IPAA) and orthotopic liver transplantation (OLT). Methods A retrospective analysis was performed of 32 patients undergoing both IPAA and OLT between 1980 and 2006. Data were collected regarding demographics, indication for surgery, postoperative complications, and outcome of IPAA and OLT. Results Thirty-day mortality after either procedure was nil. The median preoperative Model for End-stage Liver Disease (MELD) score for the group with initial IPAA was 8 (range 6–20) and the postoperative score was 11 (range 6–19). At 1 and 10 years, 32 and 26 of the 32 liver grafts had survived, and 31 and 30 of the 32 pouches, respectively. Fourteen patients require daily medical therapy for chronic pouchitis. At a median follow-up of 3·6 (range 0·2–16·2) years after the second of two procedures, responding patients reported a median of 5·5 stools per day and 2 stools per night. Conclusion IPAA and OLT are feasible and safe in patients requiring both procedures for ulcerative colitis and PSC. Functional outcomes are stable over time, despite an increased risk of chronic pouchitis.

Abstract Anal canal pressure gradient and ileal pouch motor activity were studied in continent and incontinent patients after ileal pouch-anal anastomosis. A multichannel microtransducer catheter was positioned in eight continent and eight incontinent patients 15 months or more after operation and 24-h ambulatory motor activity recorded. Resting anal pressures were significantly lower for incontinent patients during the day and night. The frequency of high-pressure waves was identical in both groups, but peak pressures were higher for incontinent patients. For continent patients, each high-pressure wave was accompanied by a rapid increase in anal canal pressure such that pressure in the pouch was always less than that in the anal canal. For incontinent patients this response was often absent. Incontinent patients had lower resting pressure, more prolonged anal canal relaxation, higher amplitude high-pressure waves and a non-responsive anal canal; the anal canal pressure gradient was therefore frequently reversed.

Abstract Anal canal length, anal canal resting and squeeze pressures, ileal pouch capacity and pouch compliance were measured in 104 patients after ileal pouch—anal anastomosis but before ileostomy closure. The intention was to determine if such parameters were associated with late functional outcome after re-establishment of intestinal continuity. Functional outcome in terms of stool frequency (day and night), incontinence (day and night), perianal pad use, perianal skin irritation, and the use of constipating agents was assessed for all 104 patients 1 year or more (median 438 days) after ileostomy closure. A low mean anal sphincter resting pressure before ileostomy closure was associated with subsequent nocturnal incontinence (P < 0·05) and, to a lesser extent, the need to use constipating agents (P = 0·08). Pouch compliance if low before ileostomy closure was associated with an increased frequency of nocturnal stool frequency after 1 year (P < 0·05). Anal canal length, anal sphincter squeeze pressure and pouch capacity before ileostomy closure were not related to subsequent functional outcome in these patients.

Abstract The surgical management of locally recurrent rectal cancer may involve major procedures and is not for the faint-hearted. Nevertheless, such treatment is preferable to chemotherapy and radiotherapy; the latter will fail over a period of months during which the patient is likely to experience intractable pain. Radical surgery offers good palliation and a better quality of life. Survival is prolonged by such operations which may be curative in up to one-third of patients. Nevertheless, surgeons must be realistic in their assessment of and discussions with patients.