Pembérton, John H.

Abstract Background Ileal pouch–anal anastomosis (IPAA) is performed routinely for chronic ulcerative colitis. Methods Using data from a prospective database and annual standardized questionnaires, functional outcome, complications and quality of life (QoL) after IPAA were assessed. Results Some 1885 IPAA operations were performed for chronic ulcerative colitis over a 20-year period (mean follow-up 11 years). The mean age at the time of IPAA was 34·1 years, increasing from 31·2 years (1981–1985) to 36·3 years (1996–2000). The overall rate of pouch success at 5, 10, 15 and 20 years was 96·3, 93·3, 92·4 and 92·1 per cent respectively. Mean daytime stool frequency increased from 5·7 at 1 year to 6·4 at 20 years (P < 0·001), and also increased at night (from 1·5 to 2·0; P < 0·001). The incidence of frequent daytime faecal incontinence increased from 5 to 11 per cent during the day (P < 0·001) and from 12 to 21 per cent at night (P < 0·001). QoL remained unchanged and 92 per cent remained in the same employment. Seventy-six patients were eventually diagnosed with indeterminate colitis and 47 with Crohn's disease. Conclusion IPAA is a reliable surgical procedure for patients requiring proctocolectomy for chronic ulcerative colitis and indeterminate colitis. The clinical and functional outcomes are excellent and stable for 20 years after operation.

AbstractAmong 971 patients with chronic ulcerative colitis who underwent ilealpouch anal anastomosis during an 8‐year period from January, 1982 to December 1989, 30 patients were randomly selected from each year (total = 240 patients) for an assessment of their long‐term functional results and quality of life as of 1990. Patients undergoing cholecystectomy during each of the same years served as “controls” (20 patients/year, total = 160 patients). All 400 patients completed a written questionnaire that measured bowel habits, overall quality of life, general health, and performance in sports/recreation, travel, sex life, family relationship, occupational work, social activities, and household activities. Ileo‐anal patients had more frequent stools (median, 6 stools/day) and more fecal spotting (68% of patients had episodes) than cholecystectomy patients (median, 1 stool/day, 13% had episodes,p<0.05). In spite of the altered bowel habits, 90% of ileo‐anal patients had an excellent overall quality of life, 76% enjoyed good health, and 91% had good performance scores in the areas examined. In fact, quality of life and performance were similar among ileo‐anal patients and cholecystectomy patients. Moreover, quality of life and bowel habits remained steady in both groups of patients during the 8‐year follow‐up. In conclusion, functional results were satisfactory and quality of life was excellent after ileal pouch‐anal anastomosis; neither deteriorated as patients aged over an 8‐year period after operation.

AbstractThe ileal pouch‐anal operation is the procedure of choice for those suitable patients requiring surgery for chronic ulcerative colitis or familial adenomatous polyposis. The functional results are generally good but pouchitis remains a significant and poorly understood complication. This review encompasses factors relating to pouchitis, e.g., bacteriological, functional and histological changes, with emphasis on its biology and treatment, and the long‐term implications.

AbstractWith few exceptions, proctocolectomy is the treatment of choice for patients with chronic ulcerative colitis. The method by which patients are offered control of bowel function postoperatively, however, is more controversial. Traditionally, proctocolectomy is accompanied by a conventional Brooke ileostomy and control of enteric effluent provided by an external appliance. Today, several alternatives are available, such as Kock's continent ileostomy and the ileoanal anastomosis. The results of both are generally good. The functional outcome of these procedures is, however, not always uniform and not all patients are candidates for such alternatives. Conventional ileostomy, therefore, remains the standard surgical approach; Brooke ileostomy is the one procedure which is applicable to any patient regardless of age, body habitus, type of disease, or other medical problems. It is the aim of this article to summarize important principles of surgical technique and of stomal care, to detail the functional results and physiologic consequences of standard ileostomy, and to document the impact of ileostomy on quality of life. Finally, the current and future role of ileostomy in the era of surgical alternatives will be discussed.

AbstractThe motor function of the ileal J pouch after ileal pouch‐anal anastomosis has a key role in the clinical outcome. The pouch forms a neorectum that aids in the maintenance of reasonable continence. The maximum capacity of the pouch (mean, 320 ml) is similar to that of the healthy rectum (330 ml). The pouch accommodates to distension, keeping intrapouch pressure low as the pouch gradually fills with stool. The change in pouch volume with each change in pressure (15 ml/mm Hg) approximates that of the healthy rectum (19 ml/mm Hg). When a threshold volume of about 150 ml is reached, large‐amplitude (>25 mm Hg), prolonged (40–60 sec), propulsive waves appear in the pouch. They initiate the call to stool. With continuing distention of the pouch to its functional capacity, which is about 200 ml, reflux of stool into the distal ileum begins, the large pressure waves become more frequent, and the urge for defecation more intense. Defecation is voluntary, spontaneous, and rapid (11 ml/sec), with the pouch and distal ileum emptying concurrently. About 60% of the pouch content, a volume of about 100 ml of stool, is discharged with each bowel movement. The greater the threshold volume and the more complete the evacuation, the fewer the bowel movements per day. After evacuation, the large pressure waves subside, and the next cycle of pouch filling and emptying begins.

Abstract 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 night-time 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.