Since the ileal pouch anal anastomosis (IPAA) was first described, anorectal manometry (ARM) has been used to study its physiology and function. Few studies have investigated if preoperative ARM can predict pouch function.

Pubmed, EMBASE, and the Cochrane Library databases were systematically searched. Papers detailing preoperative ARM results and postoperative functional outcomes of patients with IPAA were included. Meta-analysis with meta-regression was performed, assessing the relationship between preoperative manometric results and objective postoperative functional outcomes including frequency, seepage, pad usage and medications, and functional scoring systems including Wexner Incontinence and Oresland Scores.

Results from 31 studies were analysed. Mean resting pressure (MRP) decreased significantly (- 23.16 mmHg, 95% CI - 27.98 to - 18.35, p < 0.01) after pouch formation but before ileostomy reversal, with subsequent minor increase (3.51 mmHg, 95% CI 0.93 to 6.09, p = 0.01) by 6 months after reversal of ileostomy. Pooled bowel frequency was 5.4 per 24 h (4.90-5.91), day and night-time soiling, incontinence, and pad usage rates were 16% (9-24%), 26% (19-33%), 12% (4-20%), and 21% (13-30%) respectively. Pooled Oresland and Wexner Scores were 3.81 (2.92-4.70) and 3.45 (2.71-4.19). A significant association between preoperative MRP and Wexner Score was observed (p < 0.001). As a result of risk of bias, study heterogeneity, and variation in manometry systems, certainty of evidence was low or very low.

Preoperative predictors of function inform patient and clinician decision-making. Further investigations into the association between preoperative MRP and Wexner Score using modern ARM techniques are warranted.

To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA.

This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index.

Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51  (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function.

The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.

There is no consensus as to which ileoanal pouch design provides better outcomes after restorative proctocolectomy. This study compares different pouch designs.

A systematic review of the literature was performed. A random effects meta-analytical model was used to compare adverse events and functional outcome.

Thirty comparative studies comparing J, W, S and K pouch designs were included. No significant differences were identified between the different pouch designs with regard to anastomotic dehiscence, anastomotic stricture, pelvic sepsis, wound infection, pouch fistula, pouch ischaemia, perioperative haemorrhage, small bowel obstruction, pouchitis and sexual dysfunction. The W and K designs resulted in fewer cases of pouch failure compared with the J and S designs. J pouch construction resulted in a smaller maximum pouch volume compared with W and K pouches. Stool frequency per 24 h and during daytime was higher following a J pouch than W, S or K constructions. The J design resulted in increased faecal urgency and seepage during daytime compared with the K design. The use of protective pads during daytime and night-time was greater with a J pouch compared to S or K. The use of antidiarrhoeal medication was greater after a J reservoir than a W reservoir. Difficulty in pouch evacuation requiring intubation was higher with an S pouch than with W or J pouches.

Despite its ease of construction and comparable complication rates, the J pouch is associated with higher pouch failure rates and worse function. Patient characteristics, technical factors and surgical expertise should be considered when choosing pouch design.

Variability in functional outcome after ileal pouch-anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to use MRI to evaluate the morphology, emptying pattern and other pathology that may explain differences in functional outcome between well-functioning and poorly functioning pouch patients. A secondary aim was to establish a reference of normal MRI findings in pelvic pouch patients.

From a previous study, the best and worst functioning patients undergoing IPAA surgery between 2000 and 2013 had been identified and examined with manovolumetric tests (N = 47). The patients were invited to do a pelvic MRI investigating pouch morphology and emptying patterns, followed by a pouch endoscopy.

Forty-three patients underwent MRI examination. We found no significant morphological or dynamic differences between the well-functioning and poorly functioning pouch patients. There was no correlation between urge volume and the volume of the bony pelvis, and no correlation between emptying difficulties or leakage and dynamic MRI findings. Morphological MRI signs of inflammation were present in the majority of patients and were not correlated to histological signs of inflammation. Of the radiological signs of inflammation, only pouch wall thickness correlated to endoscopic pouchitis disease activity index scores.

It seems MRI does not increase the understanding of factors contributing to functional outcome after ileal pouch-anal anastomosis. Unless there is a clinical suspicion of perianal/peripouch disease or pelvic sepsis, MRI does not add value as a diagnostic tool for pelvic pouch patients. Endoscopy remains the golden standard for diagnosing pouch inflammation.

Variability in functional outcome after ileal-pouch anal anastomosis (IPAA) is to a large extent unexplained. The aim of this study was to perform multiple physiological and biochemical tests including an endoscopic examination with histology on IPAA patients with well and poorly functioning pouches to determine factors, or combinations thereof, contributing to functional outcome.

All patients with ulcerative colitis undergoing restorative proctocolectomy between 2000 and 2013 (N = 108) were interviewed using a pouch functioning score. The best and worst functioning quartiles were invited to undergo examination with a barostat measuring pouch volume at preset variable distension pressures, and a pouch endoscopy.

Forty five of 58 eligible patients agreed to participate. The most significant physiological parameter differing between the well and poorly functioning pouches was pouch volume at first sensation, urge and discomfort (p value <.001). Urge volumes were 213 (CI 171-256) ml for poorly and 352 (CI 305-401) ml for well functioning pouches. Pouchitis episodes were negatively correlated to function. The poorly functioning patients had a higher prevalence of histological signs of inflammation and hand-sewn anastomosis, and a longer remaining rectal cuff, however, nonsignificant. The pouch pressure at sensation thresholds did not differ between the groups.

Pouch volume is the most dominant predictor of pouch function in this study. The present comprehensive study of a multitude of different factors that possibly could be contributing to functional outcome, failed to shed much further light on the functional variability among pouch patients. The pouch physiology remains to a large extent unexplained.

Surgical technique constantly evolves in response to the pressure of progress. Ileal pouch anal anastomosis (IPAA) is a good example. We analysed the effect of changes in practice on the technique of IPAA and its outcomes.

Patients undergoing primary IPAA at this institution were divided into three groups by date of the IPAA: those operated from 1983 to 1993, from 1994 to 2004 and from 2005 to 2015. Demographics, patient comorbidity, surgical techniques, postoperative outcomes, pouch function and quality of life were analysed.

In all, 4525 patients had a primary IPAA. With each decade, increasing numbers of surgeons were involved (decade I, 8; II, 16; III, 31), patients tended to be sicker (higher American Society of Anesthesiologists score) and three-staged pouches became more common. After an initial popularity of the S pouch, J pouches became dominant and a mucosectomy rate of 12% was standard. The laparoscopic technique blossomed in the last decade. 90-day postoperative morbidity by decade was 38.3% vs 50% vs 48% (P < 0.0001), but late morbidity decreased from 74.2% through 67.1% to 30% (P < 0.0001). Functional results improved, but quality of life scores did not. Pouch survival rate at 10 years was maintained (94% vs 95.2% vs 95.2%; P = 0.06).

IPAA is still evolving. Despite new generations of surgeons, a more accurate diagnosis, appropriate staging and the laparoscopic technique have made IPAA a safer, more effective and enduring operation.

Restorative proctocolectomy (RPC) is the standard of care in the case of medically refractory disease and in neoplasia in ulcerative colitis (UC).

This review aims at providing an overview of the current evidence on standards, innovations, and controversies with regard to the surgical technique of RPC.

RPC is the standard of care in the surgical management of UC refractory to medical treatment and in neoplasia. Due to its simplicity and good functional outcomes, the J‑pouch is the most used pouch design. RPC is usually performed as a two-stage procedure. In the presence of risk factors, a three-stage procedure should be performed. The technically more demanding mucosectomy and hand sewn anastomosis does not seem to result in a better oncologic outcome than stapled anastomosis. Functional results appear marginally better after stapled anastomosis, but the rectal cuff should not exceed 2 cm in this reconstruction. The laparoscopic approach is at least as good as the open approach. For the new, innovative surgical approaches such as robotics and transanal surgery, only feasibility but no advantages have yet been demonstrated.

The evidence in regard to controversial points remains limited.

The object of this study was to compare function and quality of life after restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA) surgery having two different pouch designs.

Patients having RPC in an academic unit from 2000 who had had the loop-ileostomy closed by June 2013 were identified from the hospital medical records. They were sent a questionnaire regarding quality of life and interviewed using a pouch function score (PFS) described by Oresland (score 0-16, higher scores denote worse function).

One hundred and three patients underwent surgery, of whom 56 had a J-pouch design and 47 a K-pouch design, this being a double-folded Kock pouch without the nipple valve. No patients have had the pouch removed or defunctioned due to failure at a mean of 8 years. The reoperation rate was 11.6%. The mean PFS was 5.43 and 5.27 for J- and K-pouches, respectively (P = 0.766). More patients with a J-pouch reported a social handicap due to poor bowel function (P = 0.041). Patients with a PFS ≥ 8 had a poorer quality of life. A score of ≥ 8 was reported by 16% of K-pouch and 25% of J-pouch patients (P = 0.29).

RPC is a safe procedure with a low complication rate and good functional outcome. Small improvements in function have an impact on a patient's quality of life. Although the J-pouch is the most commonly used, the K-pouch has some advantages. Other pouch designs deserve further evaluation.

There are no published studies comparing pouch configurations and long-term adverse outcomes.

To evaluate outcomes of ulcerative colitis (UC) patients undergoing restorative proctocolectomy with S-, J- pouches or continent ileostomy (CI).

We conducted a historical cohort study from the prospectively maintained Pouch Registry. Demographic and clinical variables were evaluated with univariate and multivariable analyses.

Fourty-five patients with S pouches and 36 with CI (33 K pouches and 3 Barnett continent ileal reservoirs) were compared with 215 J pouches serving as controls (ratio 1:2.5). In multivariable analysis, patients with S pouches were 93% less likely to develop chronic antibiotic-refractory pouchitis (CARP) than subjects with J pouches (odds ratio [OR]=0.07; 95% confidence interval: <0.001, 0.54; p<0.001). However, no significant difference in the frequency of CARP was found between the CI and J pouch groups (OR=0.68; 95% confidence interval: 0.17, 2.00, p=0.40). Patients with S pouches were 8 times more likely (95% confidence interval: 3.7, 17.5; p<0.001) and patients with CI 5.6 had times more likely (95% confidence interval: 2.4, 13.3; p<0.001) to have pouch surgery-related complications than those with J pouches. There was no difference in the rate of CD of the pouch, pouch-associated hospitalization and pouch failure between the S- pouch, CI and J- pouch groups.

Patients with J pouches appeared to have a greater risk for chronic pouchitis than those with S-pouches and but had a lower risk for developing pouch surgery-related complications than those with S pouches or CI.

Functional outcome is of utmost importance after ileal pouch-anal anastomosis. Although pouch design and construction of the anastomosis are known technical determinants of function, there are few long-term results. This retrospective study evaluated functional outcome for two different pouch designs, and for handsewn versus stapled pouch-anal anastomoses.

The analysis included 412 patients who had either a J or K pouch (double-folded J pouch), of whom 123 had a J pouch (96 handsewn and 27 stapled) and 289 had a K pouch (95 handsewn and 194 stapled). Functional outcome was evaluated by a mailed questionnaire to achieve an Oresland score (0 to 15; 15 worst).

Mean functional scores were 6.1 for J pouches and 4.9 for K pouches (P < 0.001). Regression analysis showed that reservoir design and age at surgery were predictors of functional outcome (P < 0.001). A higher proportion of patients with a J pouch and handsewn anastomosis than with a K pouch and stapled anastomosis had a score of 8 or more, a level previously demonstrated to impact negatively on quality of life (32 versus 16 per cent; P = 0.006).

The K pouch was associated with a better long-term functional outcome than the J pouch in this patient population.

Restorative procto-colectomy with ileal pouch anal anastomosis has become the most common elective surgical procedure for patients with ulcerative colitis and is becoming popular in those with familial adenomatous polyposis coli. The procedure itself is primarily carried out in specialist surgical centres but an increasing number are being performed and followed up in district general hospitals. These patients are now filtering through general surgical and gastroenterology clinics and are frequently seen in primary care. Pouchitis, an inflammatory condition of the ileal pouch, has become the third most important form of inflammatory bowel disease. As research develops in this area, other complications are being found. The aim of this review is to provide an up-to-date, evidence-based approach to the clinical management of these patients.

Chronic refractory pouchitis is a long-term complication after ileal pouch-anal anastomosis and it may be associated with ileal inflammation.

To determine the efficacy of infliximab in treatment of chronic refractory pouchitis complicated by ileitis, using a wireless capsule endoscopy.

Sixteen patients with chronic refractory pouchitis complicated by ileitis were enrolled. Pouchitis was diagnosed by clinical, endoscopic and histological criteria. Ileitis was documented using wireless capsule endoscopy. Duodenum-jejunum and proximal-middle ileum were evaluated and the presence of small lesions and large lesions were noted. Crohn's disease, intestinal infections were excluded in all patients. Patients were treated with infliximab and clinical response was recorded. Wireless capsule endoscopy was repeated at week 10 and Pouchitis Disease Activity Index score was determined.

Ten patients were enrolled and completed the study. Clinical remission was achieved in nine patients. At wireless capsule endoscopy and pouch endoscopy, a complete recovery of lesions was observed in eight patients. One patient presented four small lesions of the ileum at the 6 weeks of treatment and one patient did not show any modification. Clinical and endoscopic remission was maintained in these eight patients at least 6 months.

These preliminary results indicate that infliximab may be recommended for the treatment of chronic refractory pouchitis complicated by ileitis.

Pouchitis is a common long-term complication after ileal pouch anal anastomosis for ulcerative colitis. Chronic refractory pouchitis is a treatment-resistant condition that affects 5-15% of patients.

To test the hypothesis of a small bowel involvement using wireless capsule endoscopy.

This is a single-blind, prospective, cohort study. Twenty-four patients: 16 were patients with chronic refractory pouchitis and eight, with a macroscopically and histologically normal ileal pouch, were considered as control subjects. Diagnosis of pouchitis was confirmed using the pouchitis disease activity index. All subjects were submitted to wireless capsule endoscopy procedure. Within 2 weeks before wireless capsule endoscopy, patients underwent a pouch endoscopy and a small bowel follow-through. Re-examination of the colonic surgical and histological specimens was also performed.

One patient with chronic pouchitis was excluded because of incomplete bowel cleaning. At small bowel follow-through of 16 patients, two subjects (13%) showed only a focal ectasia of the middle ileum and a substenosis of the pouch. At wireless capsule endoscopy all the 15 evaluable patients with chronic pouchitis (100%) showed diffuse lesions from duodenum to ileum consisting of aphthae, erosions, erythema, atrophy, cobblestone, deep/fissural ulcers.

This enteropathy needs further research, and wireless capsule endoscopy could be useful to show involvement of small bowel in patients with chronic pouchitis.

The choice of ileal pouch reservoir has been a contentious subject with no consensus as to which technique provides better function. This study aimed to compare short- and long-term outcomes of three ileal reservoir designs.

Comparative studies published between 1985 and 2000 of J, W and S ileal pouch reservoirs were included. Meta-analytical techniques were employed to compare postoperative complications, pouch failure, and functional and physiological outcomes. Quality of life following surgery was also assessed.

Eighteen studies, comprising 1519 patients (689 J pouch, 306 W pouch and 524 S pouch) were included. There was no significant difference in the incidence of early postoperative complications between the three groups. The frequency of defecation over 24 h favoured the use of either a W or S pouch [J vs S: weighted mean difference (WMD) 1.48, P < 0.001; J vs W: WMD 0.97, P = 0.01]. The S pouch was associated with an increased need for pouch intubation (S vs J: OR 6.19, P = 0.04). The use of a J pouch was associated with a significantly higher prevalence of use of anti-diarrhoeal medication (J vs S: OR 2.80, P = 0.01; J vs W: OR 3.55, P < 0.001).

All three reservoirs had similar perioperative complication rates. The S pouch was associated with the need for anal intubation. There was less frequency and less need for antidiarrhoeal agents with the W rather than the J pouch.

Ileal pouch-anal anastomosis (IPAA) has become the standard of care for the 25% of patients with ulcerative colitis who ultimately require colectomy. IPAA is favored by patients because it avoids the necessity for a long-term stoma. This review examines how 3 decades of experience with IPAA has molded current practice, highlighting 5- and 10-year follow-up of large series to determine durability and functional performance, in addition to causes of failure and the management of complications.

The principal aim of the present investigation was to study the general QoL and disease-specific adjustment before, and one-year after, operation with an ileal pouch anal-anastomosis (IPAA) in a consecutive series of patients with ulcerative colitis (UC).

Eleven patients were medically treated and 31 patients underwent colectomy with ileostomy. The patients were interviewed before the IPAA operation and again one-year after closure of the covering loop ileostomy. General quality of life was estimated with a Swedish instrument (according to Kajandi, score range 16-96) and a VA-scale. The instrument for disease-specific adjustment contained specific questions with five factors (score range 34-204). Open questions about quality of life were used to identify areas of concern, which were not included in the other instruments. Postoperative function was described in terms of a functional score (score range 0-15).

The results of the general quality of life assessments did not differ significantly when comparing pre-operative to postoperative values. Disease-specific adjustment showed that the medically treated patients had a score of 162; interquartile range (IQR) 145-176. The patients with ileostomy scored 164; IQR 141-180. Postoperatively there was a statistically significant improvement in both groups to 189 (IQR 172-199), an increase of 15%. The open questions revealed restrictions in daily life for both patient groups pre-operatively with improvements after IPAA. The median grading of functional outcome according to the score system was 2. The most frequent problems were: patients who had occasional bowel movements at night, 40%; intermittent perianal soreness, 51%; antidiarrhoeal medication use, 61%.

General QoL did not change after IPAA. The bowel-specific adjustment in most factors improved in the majority of patients after IPAA. However, half of the IPAA patients had occasional bowel movements at night perianal soreness, and used antidiarrhoeal medication.

The physiological and clinical effects of loperamide treatment versus placebo were investigated in a randomized, double-blind, crossover study in patients operated with restorative proctocolectomy. Sixteen patients operated with endoanal mucosectomy and a handsewn ileal pouch-anal anastomosis and 14 patients operated with abdominal proctocolectomy and stapling of the pouch to the top of the anal canal were studied. While loperamide treatment increased resting anal pressure in both groups of patients by approximately 20% (P < 0.05), squeeze pressure was not affected. Loperamide did not affect pouch volume or contractility. Sensory thresholds and the recto/pouch-anal inhibitory reflex were not influenced by loperamide treatment. Clinical function was improved, with a reduced bowel frequency and an improved nighttime continence, with less soiling (P < 0.05) as well as need to wear a protective pad.

The decreased anal sphincter pressure that occurs after ileal pouch-anal canal anastomosis (IPAA) has usually been attributed to damage of the internal and sphincter. We hypothesized that the operation damages both the internal and the external anal sphincter. Resting pressure in the anal canal (a function of internal and external sphincters), anal squeeze pressure (a function of external sphincter only), and the rectal-anal inhibitory reflex (involving the internal sphincter) were measured manometrically in 10 patients with ulcerative colitis (4 women and 6 men; mean age, 33 years; range: 20 to 49 years). The patients were studied while awake before IPAA, under general anesthesia with striated muscle blockade just before incision, awake 2 months later before ileostomy takedown, and again under anesthesia with blockade just before takedown. The operation decreased maximum resting anal pressure while awake and during anesthesia with blockade. The decrease was detected in the proximal anal canal but not in the distal anal canal. In addition, the operation impaired anal squeeze pressure and abolished the rectal-anal inhibitory reflex. We conclude that IPAA damages both the internal and the external anal sphincter.

There are numerous surgical options for the treatment of mucosal ulcerative colitis.

This article reviews the currently available options for the treatment of mucosal ulcerative colitis. Separate discussions will explore both the options in the emergency and elective settings.

Patients with mucosal ulcerative colitis may undergo surgery either as an emergency or in the elective setting. Emergency surgery is usually performed for one of the life-threatening complications of ulcerative colitis: fulminant colitis, toxic megacolon, or massive hemorrhage. The most commonly performed procedure under these conditions is a subtotal colectomy with end ileostomy. The rectal stump may be handled in a variety of ways. This procedure avoids proctectomy or anastomosis. Thus, patients will still have all necessary anatomic structures to allow for any of the definitive elective procedures. Elective surgery is performed for intractable disease, complications of medical therapy, dysplasia, or, occasionally, extraintestinal manifestations. In the elective setting, a definitive operation can be done to remove most or all of the disease-bearing colorectum and leave the patient with a means to control fecal elimination. Total abdominal colectomy with ileorectal anastomosis leaves the patient with diseased bowel but obviates the need for pelvic dissection. Although total proctocolectomy removes all potentially diseased mucosa, these patients have a permanent ileostomy. The stoma can either be a standard Brooke's ileostomy or a continent Kock pouch. The most common definitive procedure currently performed is the near-total proctocolectomy with ileal pouch-anal anastomosis. This option can be completed either with a rectal mucosectomy and hand-sewn anastomosis or with a double-stapled anastomosis, preserving the anal transition zone. This procedure is successful in eradicating almost all diseased mucosa while allowing the patient per anal defecation. Bowel movement frequency, degree of anal continence, and return to social and professional commitments have met with a great deal of satisfaction in most patients. A newer alternative to this procedure employs laparoscopy to facilitate a smaller incision. A one-stage procedure which omits the protective ileostomy and thus saves the patient one operation has also been used with some success in selected cases.

There are several surgical options for the treatment of mucosal ulcerative colitis. Each one has a role and should be discussed with the patient.

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.

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.

At one year, the drop in mean anal canal resting pressure was 13 percent in the high cuff group (not significant) 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 H2O) 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 < or = 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.

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.

Peroperative manometry was performed in 12 patients operated on with endoanal proctectomy and a hand-sewn pouch-anal anastomosis and in 12 in whom proctectomy was performed entirely from above, with the ileal pouch stapled to the top of the anal canal. Results from both groups showed that division of the superior rectal artery reduced the median (95 per cent confidence interval (c.i.)) resting anal pressure from 77.5 (69.9-83.3) mmHg to 64.5 (55.2-70.0) mmHg (P < 0.01). Complete rectal mobilization to the pelvic floor decreased resting pressure by an additional 22 per cent, to a median of 50.0 (95 per cent c.i. 40.1-53.5) mmHg (P < 0.01). After completion of anastomosis, irrespective of the operative technique used, a further decline in median pressure to 35.0 (95 per cent c.i. 26.0-47.7) mmHg could be demonstrated (P < 0.05). This study indicates that anal sphincter pressure is reduced to a similar extent after hand-sewn and stapled anastomoses. Injury to the autonomic nervous supply to the anal sphincter mechanism might be the major cause for this reduction.

Three anal sphincter-saving operations--ileorectostomy, ileal pouch-anal anastomosis, and ileal pouch-distal rectal anastomosis--are currently being used in the surgical treatment of chronic ulcerative colitis. All three operations remove the disease, or most of it, and yet they maintain transanal defecation, reasonable fecal continence, and a satisfactory quality of life. All three avoid permanent abdominal ileostomy. Ileorectostomy is the easiest to perform, but it leaves residual disease in the remaining rectum and proximal anal canal that may cause symptoms and that may predispose the patient to cancer. In contrast, ileal pouch-anal anastomosis, although a more technically demanding procedure, totally eradicates the colitis. Its main drawbacks--frequent stooling, nocturnal fecal spotting, and pouchitis--are usually satisfactorily treated with loperamide hydrochloride and metronidazole. Ileal pouch-distal rectal anastomosis is somewhat easier to perform than ileal pouch-anal anastomosis and may result in less nocturnal fecal spotting. Like ileorectostomy, however, the operation leaves residual disease in the distal rectum and proximal anal canal. Considering all of these factors, the ileal pouch-anal operation is preferred today for most patients who require surgery for chronic ulcerative colitis.

Thirty patients were operated on with restorative proctocolectomy with an end-to-end ileal pouch-anal anastomosis constructed by double stapling (STP). Pouches were randomized to either J type or K type (folded by the principles used for the Kock continent ileostomy). Manovolumetric and functional results were compared. Patients were followed up for at least 6 months. K pouches acquired a significantly larger volume than the J-configurated pouches, and at 6 months the mean +/- SD volumes amounted to 361 +/- 59.8 ml versus 283 +/- 43.0 ml (p less than 0.01) with a concomitant reduction in 24-h frequency (4.4 +/- 1.5 versus 5.8 +/- 1.9; p less than 0.05). The initial postoperative mean reduction of resting anal pressure amounted to 33%. which was similar to that observed in a group of matched historical controls operated on with endoanal mucosectomy and hand-sutured pouch-anal anastomosis. Compared with these controls STP patients showed a superior overall functional result, most marked in the early postoperative period.