Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice for patients requiring surgery for inflammatory bowel disease. A stricture located at the inlet of the afferent limb can lead to small bowel obstruction in a limited number of patients with a pelvic pouch. This paper aims to examine our experience with afferent limb stricture surgical correction when other endoscopic treatment methods have failed to control obstructive symptoms.

All consecutive eligible patients with ileal pouch-anal anastomosis and afferent limb stricture were identified from our institutional review board-approved database from 1990 to 2021. Patients surgically treated with excision and reimplantation/strictureplasty of afferent limb stricture were included in this study.

Twenty patients met our inclusion criteria. Fifteen (75%) were female, and the overall mean age was 41 ± 10.3 years at afferent limb stricture surgery. The interval from ileal pouch-anal anastomosis formation to surgery for afferent limb stricture was 13.5 ± 6.7 years. Nine (45%) underwent strictureplasty, and 11 (55%) had resection and reimplantation of the afferent limb into the pouch. Before afferent limb stricture surgery, 3 (15%) required a diverting ileostomy for their obstructive symptoms. An additional 12 (60%) had a stoma constructed during afferent limb stricture surgery, and 5 had a strictureplasty and no stoma. Postoperatively, 1 patient (5%) had a leak at the afferent limb stricture repair site. All patients had their ileostomy closed 3.2 (2.99-3.6) months after surgery. Long-term after afferent limb stricture surgery, recurrent small bowel obstruction symptoms recurred in 7 (35%) patients 3.9 (2.6-5.8) years later.

Afferent limb stricture can be treated effectively with salvage surgery. The surgical intervention appears durable and provides an acceptable outcome for their obstructive symptoms.

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Strictures are common complications after ileal pouch surgery. The aim of this study is to evaluate the efficacy and safety of endoscopic stricturotomy vs. endoscopic balloon dilation (EBD) in the treatment of pouch inlet strictures.

All consecutive ulcerative colitis patients with the diagnosis of pouch inlet or afferent limb strictures treated in our Interventional Inflammatory Bowel Disease Unit (i-IBD) from 2008 to 2017 were extracted. The primary outcomes were surgery-free survival and post-procedural complications.

A total of 200 eligible patients were included in this study, with 40 (20.0%) patients treated with endoscopic stricturotomy and 160 (80.0%) patients treated with EBD. Symptom improvement was recorded in 11 (42.3%) patients treated with endoscopic stricturotomy and 16 (13.2%) treated with EBD. Subsequent surgery rate was comparable between the two groups (9 [22.5%] vs. 33 [20.6%], P = 0.80) during a median follow-up of 0.6 years (interquartile range [IQR] 0.4-0.8) vs. 3.6 years (IQR 1.1-6.2) in patients receiving endoscopic stricturotomy and EBD, respectively. The overall surgery-free survival seems to be comparable as well (P = 0.12). None of the patients in the stricturotomy group developed pouch failure, while 9 patients (5.6%) had pouch failure in the balloon dilation group (P = 0.17). Procedural bleeding was seen in three occasions (4.7% per procedure) in patients receiving endoscopic stricturotomy and perforation was seen in three occasions (0.8% per procedure) in patients receiving EBD (P = 0.02). In multivariable analysis, an increased length of the stricture (hazard ratio [HR] 1.4, 95% confidence interval [CI] 1.0-1.8) and concurrent pouchitis (HR 2.5, 95% CI 1.0-5.7) were found to be risk factors for the requirement of surgery.

Endoscopic stricturotomy and EBD were both effective in treating patients with pouch inlet or afferent limb strictures, EBD had a higher perforation risk while endoscopic stricturotomy had a higher bleeding risk.

Colorectal pediatric surgery is a diverse field that encompasses many different procedures. The pullthrough for Hirschsprung disease, the posterior sagittal anorectoplasty for anorectal malformations including complex cloaca reconstructions and the ileal pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis present some of the most technically challenging procedures pediatric surgeons undertake. Many children prevail successfully following these surgical interventions, however, a small number of patients suffer from complications following these procedures. Anticipated postoperative problems are discussed along with medical and surgical strategies for managing these complications.

The accepted current standard for treatment of medically refractory ulcerative colitis is total proctocolectomy with an ileal pouch-anal anastomosis for restoration of continence. There are 2 techniques by which the anastomosis can be performed, including handsewn and stapled. Handsewn anastomosis with mucosectomy was the first method described; however, it has been associated with significant incontinence. The double-stapled anastomosis was developed in response to improve postoperative function. Controversy remains as to which technique is superior as both have disadvantages. This review article addresses differences between the 2 methodologies in relation to postoperative complications, anorectal physiology, functional outcomes, and oncological safety.

The efferent limb on the S-pouch fits well into the anal canal while the body of the pouch lies on the levators. In contrast, the blunt end of a J-pouch may be distorted as it is forced into the muscular tube of the stripped anus.

The aim of this study is to compare the clinical outcomes and quality of life between patients with S- and J-pouches with a handsewn IPAA.

This study was retrospective.

This study was conducted at a high-volume tertiary referral center.

Patients undergoing a primary handsewn IPAA from 1983 to 2012 were identified.

Demographics, operative details, functional outcomes, and quality of life were abstracted.

A total of 502 patients, including 169 patients with an S-pouch (33.7%) and 333 patients with J-pouch (66.3%), met our inclusion criteria; 55.8% (n = 280) were men. Mean age at pouch construction was 37.8 ± 12.5 years. Patients with an S-pouch were younger (p = 0.004) and had a higher BMI (p = 0.035) at pouch surgery. There was no significant difference between patients with S- or J-pouches in other demographics. The frequencies of short-term complications in the 2 groups were similar (p > 0.05), but pouch fistula or sinus (p = 0.047), pelvic sepsis (p = 0.044), postoperative partial small-bowel obstruction (p = 0.003), or postoperative pouch-related hospitalization (p = 0.021) occurred in fewer patients with an S-pouch. At a median follow-up of 12.2 (range, 4.3-20.1) years, patients with an S-pouch were found to have fewer bowel movements (p < 0.001), less frequent pad use (p = 0.001), and a lower fecal incontinence severity index score (p = 0.015). The pouch failed in 62 patients (12.4%), but neither univariate nor multivariate analysis showed a significant association with pouch configuration.

The use of data from a single tertiary referral center was a limitation of this study.

We recommend using an S-pouch when constructing an IPAA with a handsewn technique.

Refractory distal ulcerative colitis (RDUC) is defined as persistence of symptoms caused by endoscopically proven colonic inflammation located at the rectum or left colon despite oral/topical steroids and 5-ASA. RDUC affects a small subset of patients and is associated with chronic disabling symptoms and increased social/medical costs. Moreover, patients with long-standing ulcerative colitis (UC) carry an elevated risk of developing colorectal cancer and colonic mucosa high-grade dysplasia. Alternative medical strategies in steroid refractory disease are unlikely to provide durable remission in all patients, carry potential severe side effects and, as immunosuppressants, the risk of other neoplasms, and may increase the short-term complication rate when surgery is finally required. Restorative proctocolectomy with ileal pouch-anal anastomosis (RP-IPAA) allows the complete removal of the diseased rectum and colon, virtually eliminating the risk of malignant transformation and reestablishing intestinal continuity with continence preservation. Since the introduction of this surgical procedure, morbidity and mortality rates have been drastically reduced. Despite the still notable rate of surgical complications, long-term quality of life assessment has shown excellent results in nearly all patients who have undergone RP-IPAA, comparing well with the general population. Furthermore, when performed for distal UC, RP-IPAA produces similar surgical outcomes with respect to pancolitis. In conclusion, RP-IPAA should always be considered in patients with RDUC, and multidisciplinary counseling should provide patients clear information about the advantages of surgery and possible complications as well as the chance to achieve disease remission with medical therapy.

Ileal pouch-anal anastomosis (IPAA) is the operation of choice following proctocolectomy for patients who suffer from ulcerative colitis and familial adenomatous polyposis. The aim of this study was to morphologically examine the neurons, endocrine cells and mast cells in the ileum of rats subjected to proctocolectomy followed by three different types of ileoanal anastomosis. Rats were subjected to either sham operation or proctocolectomy followed by ileoanal anastomosis end-to-end, side-to-end or IPAA (J-pouch). In comparison to sham-operated rats, the body weight was reduced in rats that underwent proctocolectomy with end-to-end or side-to-end, but not IPAA procedure. In all three models of ileoanal anastomosis, the ileum displayed crypt hyperplasia with a chronic inflammatory infiltrate located in the interstitium, hyperplasia of goblet cells, but reduced protein gene product 9.5 (PGP 9.5)-immunoreactive neurons in the mucosa as well as submucosa. Numbers of endocrine cells in the mucosa (chromogranin A immunostaining) and mast cells in the mucosa and submucosa (Astra blue staining) were unchanged after proctocolectomy. In conclusion, neurons, but neither endocrine cells nor mast cells, were reduced in the ileum of proctocolectomized rats followed by either of three different types of ileoanal anastomosis.

Ileal pouch-anal anastomosis is currently accepted as the standard method to restore continence after total proctocolectomy for medically refractory ulcerative colitis and familial adenomatous polyposis. Ileal pouches offer improved quality of life and high patient satisfaction; however, there are many pouch-related complications due to the original disease process and change in anatomy. This is a review article of the common and some rare surgical complications after J pouches, which can be subdivided into the septic and nonseptic categories. Septic-related complications include anastomotic leak, abscess, and fistulas, whereas common nonseptic-related complications include small bowel obstruction, strictures, Crohn's disease, pouchitis, and cuffitis. Rare nonseptic complications to be discussed are prolapse, volvulus, and neoplasia.

Perianal symptoms are common in patients with Crohn's disease and cause considerable morbidity. The etiology of these symptoms include skin tags, ulcers, fissures, abscesses, fistulas or stenoses. Fistula is the most common perianal manifestation. Multiple treatment options exist although very few are evidence-based. The phases of treatment include: drainage of infection, assessment of Crohn's disease status and fistula tracts, medical therapy, and selective operative management. The impact of biological therapy on perianal Crohn's disease is uncertain given that outcomes are conflicting. Operative treatment to eradicate the fistula tract can be attempted once infection has resolved and Crohn's disease activity is controlled. The operative approach should be tailored according to the anatomy of the fistula tract. Definitive treatment is challenging with medical and operative treatment rarely leading to true healing with frequent complications and recurrence. Treatment success must be weighed against the risk of complications, specially anal sphincter injury. A full understanding of the etiology and all potential therapeutic options is critical for success. Multidisciplinary management of fistulizing perianal Crohn's disease is crucial to improve outcomes.

The objective of this study was to evaluate the efficacy of stricturoplasty and endoscopic balloon dilatation in the treatment for ileal pouch strictures.

Consecutive inflammatory bowel disease patients with pouch strictures seen at our Pouch Center from 2002 to 2012 were studied. The efficacy and safety of stricturoplasty (vs. endoscopic balloon dilation) were evaluated with both univariate and multivariate analyses.

A total of 167 patients met the inclusion criteria, including 16 (9.6 %) with surgical stricturoplasty and 151 (90.4 %) with endoscopic balloon dilation. Ninety-four patients (56.3 %) were male, with a mean age at the diagnosis of pouch stricture of 41.6 ± 13.2 years. Fifty-one patients (30.5 %) had multiple pouch strictures, while 100 (59.9 %) patients had strictures at the pouch inlet. The mean length of pouch strictures was 1.2 ± 0.6 cm. No difference was found between the stricturoplasty and endoscopic dilation groups in clinicopathological variables, except for the degree of strictures (p = 0.019). After a mean follow-up of 4.1 ± 2.6 years, pouch stricture recurred in 92 patients (55.1 %) and 21 (12.6 %) patients developed pouch failure. The time interval between the procedure and pouch stricture recurrence or pouch failure was longer in the stricturoplasty group than that in the endoscopic dilation group (p < 0.001). Patients in the two groups had similar overall pouch survival rates and stricture-free survival rates. In the multivariate analysis, stricturoplasty vs. endoscopic dilation was not significantly associated with either overall pouch survival or stricture-free survival. There was no difference in the procedure-associated complication rates between the two groups.

Surgical stricturoplasty and endoscopic dilation treatment are complimentary techniques for pouch strictures. Repeated endoscopic dilatations are often required, while surgical stricturoplasty appeared to yield a longer time interval to stricture recurrence or pouch failure.

Total proctocolectomy with ileal pouch anal anastomosis (IPAA) preserves fecal continence as an alternative to permanent end ileostomy in select patients with ulcerative colitis and familial adenomatous polyposis. The procedure is technically demanding, and surgical complications may arise. This article outlines both the early and late complications that can occur after IPAA, as well as the workup and management of these potentially morbid conditions.

In this retrospective study, we aimed to evaluate preoperative predictive risk factors for development of pouchitis in the ulcerative colitis (UC) patients with ileal pouch-anal anastomosis (IPAA).

The records of UC patients who underwent IPAA surgery and were under follow-up in the inflammatory bowel disease (IBD) clinic of our hospital between January 1994 and September 2009 were retrieved. Preoperative clinical, biochemical, and endoscopic findings, as well as preoperative endoscopic activity index (EAI), preoperative disease activity index (DAI) and operative characteristics were recorded. Patients with endoscopic, histological and clinical findings consistent with pouchitis were identified.

Out of a total of 49 patients who underwent IPAA for UC, pouchitis was identified in 20 (40.8%) of them. Overall, 37 (75.5%) patients had chronic active disease, eight (16.3%) patients had chronic intermittent disease with frequent relapses, and four (8.2%) patients had fulminant colitis prior to surgery. There was a statistically significant difference (P=0.02) among these patients for the development of pouchitis in postoperative period. The mean EAI (10.1 vs. 8.7, P=0.02) and DAI (10.0 vs. 8.6, P<0.01) in patients with pouchitis were significantly higher than that of patients who did not develop pouchitis. Multivariate analysis revealed steroid dependency (P=0.02), and a higher DAI (P=0.02) to be independent risk factors for the development of pouchitis.

A more severe preoperative clinical course and steroid dependency, as well as higher endoscopic and disease activity scores may be useful as preoperative predictors of subsequent pouchitis in UC patients undergoing IPAA surgery.

There are numerous studies on quality of life (QoL), health-related quality of life (HRQoL), and health status (HS) in patients undergoing surgery for ulcerative colitis. A systematic review of published literature was conducted to establish the quality of these studies and to determine QoL, HRQoL, and HS in patients after ileal pouch-anal anastomosis for ulcerative colitis.

All published studies describing QoL, HRQoL, and HS in adult patients in combination with ileal pouch-anal anastomosis for ulcerative colitis were reviewed systematically. No time or language limitations were applied. Relevance was established on the basis of three pre-specified selection criteria: 1) ileal pouch-anal anastomosis was performed for ulcerative colitis, 2) QoL, HRQoL, and HS were reported as outcome of the study and 3) studies reported a minimum follow-up after surgery for 12 months. Outcome variables were results of QoL, HRQoL, and HS, characteristics of the study population, pouch construction, duration of follow-up, and time of assessment in months before and after restorative surgery. Descriptive data synthesis was performed by tabulation displaying the methodological quality, study characteristics and conclusions on QoL, HRQoL, and HS measurements in the studies.

The review included 33 studies comprising 4790 patients. Three were graded to be of high quality, 23 of moderate quality and seven of low quality. All reported improved HS and the majority reported improved HRQoL. However, none of the studies reported on QoL.

The HRQoL and HS of patients with ulcerative colitis improved 12 months after restorative proctocolectomy with an ileal pouch-anal anastomosis and were indistinguishable from the HRQoL and HS of the normal healthy population.

Endoscopic management of ileal pouch strictures has not been systemically studied. The aim was to evaluate endoscopic balloon therapy of pouch strictures in inflammatory bowel disease (IBD) patients with ileal pouches and to identify risk factors for pouch failure for those patients.

Consecutive IBD patients with pouches from the Pouchitis Clinic who underwent nonfluoroscopy-guided outpatient endoscopic therapy were studied. The location, number, degree (range 0-3), and length of strictures and balloon size were documented. Efficacy and safety were evaluated with univariate and multivariate analyses.

A total of 150 patients with pouch strictures were studied. Stricture locations were at the pouch inlet (n = 96), outlet (n = 73), afferent limb (n = 33), and pouch body (n = 2). A cumulative of 646 strictures were endoscopically dilated, with a total of 406 pouchoscopies. The median stricture score was 1 (interquartile range [IQR] 1-2); the median stricture length was 1 (IQR 0.5-1.25) cm, and the median balloon size was 20 (IQR 18-20) mm. Of 406 therapeutic endoscopies performed, there were two perforations (0.46%) and four transfusion-required bleeding (0.98%). The 5-, 10-, and 25-year pouch retention rates were 97%, 90.6%, and 85.9%, respectively. In a median follow-up of 9.6 (IQR 6-17) years, 131 patients (87.3%) were able to retain their pouches. The number of strictures and underlying diagnosis were independent risk factors for pouch failure in the Cox regression model.

Endoscopic treatment of pouch stricture appears to be efficacious and generally safe to perform in experienced hands. Underlying diagnosis of Crohn's disease of the pouch and surgery-related strictures and multiple strictures were the risk factors for pouch failure.

This observational study aimed to determine national provision and outcome following pouch surgery (restorative proctocolectomy, RPC) and to examine the effect of institutional and surgeon caseload on outcome.

All patients undergoing primary RPC between April 1996 and March 2008 in England were identified from the administrative database Hospital Episode Statistics. Institutions and surgeons were categorized according to the total RPC caseload performed over the study interval.

Some 5771 primary elective pouch procedures were undertaken at 154 National Health Service hospital trusts. Median follow-up was 65 (interquartile range (i.q.r.) 28-106) months. The 30-day in-hospital mortality rate was 0·5 per cent and the 1-year overall mortality rate 1·5 per cent. Some 30·5 per cent of trusts performed fewer than two procedures per year, and 91·4 per cent of surgical teams (456 of 499) carried out 20 or fewer RPCs over 8 years. Median surgeon volume was 4 (i.q.r. 1-9) cases. Failure occurred in 6·4 per cent of cases. Low-volume surgeons operated on more patients at the extremes of age (P < 0·001) and a lower proportion with ulcerative colitis (P < 0·001). Older age, increasing co-morbidity, increasing social deprivation, and both lower provider and surgeon caseload were independent predictors of longer length of stay. Older patient age and low institutional volume status were independent predictors of failure.

Many English institutions and surgeons carry out extremely low volumes of RPC surgery. Case selection differed significantly between high- and low-volume surgeons. Institutional volume and older age were positively associated with increased pouch failure.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical therapy of choice for patients with chronic ulcerative colitis and the majority of patients with familial adenomatous polyposis. It restores gastrointestinal continuity, re-establishes transanal defecation, and avoids a permanent stoma. Although this technically demanding procedure is associated with low mortality rates, it is frequently accompanied by early and late complications. This article will review these complications and discuss the interventions that are needed to provide appropriate treatment.

This study compared outcomes after laparoscopically assisted and open restorative proctocolectomy performed as a one-stage procedure, including anorectal mucosectomy and omission of ileal diversion.

We reviewed our prospectively maintained database of patients who underwent restorative proctocolectomy between 1998 and 2006. Demographic data, surgical indications, and intraoperative and postoperative complications were evaluated. Anastomotic leaks were identified by radiologic, endoscopic, or intraoperative evidence. The primary outcome variables were complications, duration of operation, blood loss, intraoperative spillage of enteric contents, and the ability to complete the procedure in one stage.

One-stage laparoscopically assisted restorative proctocolectomy was performed in 50 patients and open restorative proctocolectomy was performed in 155 patients. The mean operative time was longer for the laparoscopically assisted group (198.7 vs. 159.1 minutes; P = 0.006). The mean estimated blood loss was less among the patients in the laparoscopically assisted group (287.5 vs. 386.4 ml; P = 0.006). There were no significant differences in intraoperative or postoperative complications between the two groups.

Laparoscopically assisted one stage restorative proctocolectomy is a safe and technically feasible procedure. There seems to be no increase in the rate of postoperative complications compared with the open approach. Laparoscopically assisted restorative proctocolectomy should be considered in the surgical management of patients who require this procedure.

Construction of a satisfactory ileal reservoir-anal anastomosis is dependent on the ability of the reservoir to reach the anus without tension.

A literature review of English language scientific papers from Medline and Pubmed between 1978 and 2004 about ileal pouch surgery techniques was conducted.

The critical factor in tension free pouch construction is the length and reach of the superior mesenteric artery. There are a variety of techniques for lengthening the small bowel mesentery including the precise location of division of the ileocolic artery and other mesenteric vessels, mesenteric peritoneal relaxing incisions, folding of the pouch and differences between stapled and handsewn anastomosis and pouch construction.

With particular attention to detail, sufficient length can be achieved to permit safe anastomosis in most patients.

Controversy exists regarding the safety for omission of diverting ileostomy in restorative proctocolectomy because of fears of increased septic complications. This study was designed to evaluate the outcomes of restorative proctocolectomy in a consecutive series of patients by comparing postoperative complications, functional results, and quality of life in patients with and without diverting ileostomy.

Data regarding demographics, length of stay, surgical characteristics, and complications were reviewed and recorded according to the presence (n= 1,725) or absence (n = 277) of a diverting ileostomy at the time of pelvic pouch surgery. Criteria for omission of ileostomy included: stapled anastomosis, tension-free anastomosis, intact tissue rings, good hemostasis, absence of airleaks, malnutrition, toxicity, anemia, and prolonged consumption of steroids. Functional outcome and quality of life indicators were prospectively recorded and compared.

Patients in the ileostomy group had greater body surface area and older mean age at time of surgery, were taking greater doses of steroids preoperatively, and required more blood transfusions at the time of surgery compared with the one-stage (P < 0.05). There were no differences between the two groups in septic complications (P > 0.05). Early postoperative ileus was more common in the one-stage group (P < 0.001). There were no differences between the groups in quality of life and functional outcomes.

For carefully selected patients undergoing restorative proctocolectomy with ileal pouch-anal anastomosis, omission of diverting ileostomy is a safe procedure that does not lead to an increase in septic complications or mortality. Quality of life and functional results are similar to those who undergo ileal pouch-anal anastomosis with diversion, provided that certain selection factors are considered.

The aim of this study was to assess the short-term and long-term outcomes of surgical repair of patients with pouch-vaginal fistulas after restorative proctocolectomy.

A descriptive study was undertaken of all patients developing pouch-vaginal fistulas following restorative proctocolectomy between 1978 and 2003 in a single tertiary referral institution. Kaplan-Meier survival analysis was used to evaluate the time to first pouch-vaginal fistula recurrence and pouch-vaginal fistula-free survival at last follow-up.

Sixty-eight patients (mean age, 32.2 years; standard deviation, 10.7) were identified with a median follow-up of 5.5 (range, 0.2-25.5) years. The origin of the pouch-vaginal fistulas was the pouch-anal anastomosis in 52 (76.5 percent) patients, pouch body/top in 9 (13.2 percent), or cryptoglandular or other source in 7 (10.3 percent). Associated early complications in patients with pouch-vaginal fistulas included pelvic sepsis in 20 (29 percent) patients, anastomotic separation in 6 (24 percent), anastomotic stricture in 16 (24 percent), small bowel obstruction in 17 (25 percent), hemorrhage in 2 (3 percent), or pouchitis in 12 (18 percent). Surgery was undertaken in 59 (87 percent) patients with 14 (20.6 percent) of them undergoing pouch excision/diversion or seton drainage. Forty-five (66 percent) patients underwent primary repair. First recurrence of pouch-vaginal fistula occurred in 27 of 45 (60 percent) patients with a median pouch-vaginal fistula-free interval of 1.6 years (95 percent confidence interval, 0.6-2.7). Fourteen (51.9 percent) patients with recurrent pouch-vaginal fistulas healed following one or more repeat procedures. The diagnosis of Crohn's disease was made in eight (12 percent) patients, with pouch-vaginal fistulas persisting or recurring in all patients with Crohn's disease within five years of the primary treatment. Median pouch-vaginal fistula-free survival was 1.4 years for patients with Crohn's disease and 8.1 years for patients with ulcerative colitis or familial adenomatous polyposis. The pouch-vaginal fistula-free survival improved with repeated local or abdominal repairs for patients with ulcerative colitis. The overall pouch failure rate for patients with pouch-vaginal fistulas was 35 percent (median pouch survival, 4.2 years).

Pouch-vaginal fistulas can persist and recur indefinitely, even after repeated repairs. Repair in those patients with Crohn's disease uniformly failed within five years from primary repair. Patients with recurrent pouch-vaginal fistulas and ulcerative colitis should be offered salvage surgery because successful closure following initial failure occurs in approximately 50 percent.

Restorative proctocolectomy with ileal pouch-anal anastomosis is the surgical treatment of choice in patients with ulcerative colitis. Strictures can occur at the inlet and outlet of the pouch. Endoscopic balloon dilation has been successfully used in patients with Crohn's strictures at the small intestine and colon. There are no published trials on endoscopic balloon therapy of ileal pouch strictures.

To evaluate outpatient endoscopic balloon dilation of strictures in ileal pouches.

Patients underwent nonfluoroscopy-guided, nonsedated, outpatient endoscopic dilations with an 8.6-mm upper endoscope and through-the-scope balloons (size: 11-18 mm). Pre- and posttreatment Pouchitis Disease Activity Index symptom scores (range: 0-6), endoscopic stricture scores based on resistance in passing the endoscope (range: 0-4), and Cleveland Global Quality of Life were compared.

Nineteen patients with pouch strictures who had concurrent Crohn's disease of the pouch (n = 11), cuffitis (n = 5), and pouchitis (n = 3), including 14 inlet and 14 outlet strictures, were enrolled. The mean number of strictures for each patient was 1.61 +/- 0.78. All strictures were successfully dilated with the through-the-scope balloon, with a mean of 1.74 +/- 1.19 (range: 1-5) sessions for each patient. Nine patients had a second endoscopy at 8 wk and five patients had a third pouch endoscopy at 16 wk after the initial endoscopic dilation. Endoscopic stricture scores immediately (0.30 +/- 0.47), 8 wk (0.40 +/- 0.51), and 16 wk (0.44 +/- 0.76) after the dilation were significantly improved compared to the predilation stricture scores (2.67 +/- 0.78). The symptom scores and quality-of-life (QOL) scores improved at week 8 and 16 following dilation, with a mean follow-up of 6.10 +/- 5.83 months (2-25 months). No complications were experienced with the procedure. One patient with CD who failed endoscopic and medical therapy underwent pouch resection.

In conjunction with medical therapy, outpatient endoscopic balloon dilation appears safe and effective in treating pouch inlet and outlet strictures, by relieving symptoms, restoring pouch patency, and improving QOL in the majority of patients.

Recent studies have suggested that a subset of patients with Crohn's colitis may have a favorable outcome after ileal pouch-anal anastomosis and have advocated elective ileal pouch-anal anastomosis in selected patients with Crohn's disease. We have not offered ileal pouch-anal anastomosis to patients with known Crohn's disease, but because of the overlap in clinical presentation of ulcerative colitis and indeterminate colitis, some patients receiving an ileal pouch-anal anastomosis are subsequently found to have Crohn's disease. We review our experience with these patients to identify potential preoperative predictors of ultimate pouch failure.

Patients with a final diagnosis of Crohn's disease were identified from an ileal pouch-anal anastomosis registry. These patients are followed prospectively. Preoperative and postoperative clinical and pathologic characteristics were evaluated as predictors of outcome. Median (range) values are listed.

Thirty-two (18 females) patients (4.1 percent) with a final diagnosis of Crohn's disease were identified from a registry of 790 ileal pouch-anal anastomosis patients (1980-2002). Patients underwent ileal pouch-anal anastomosis in two stages (11 patients) or three stages (21 patients). The preoperative diagnosis was ulcerative colitis in 24 patients and indeterminate colitis in 8 patients. Median follow-up was 153 (range, 13-231) months. The median time from ileal pouch-anal anastomosis to diagnosis of Crohn's disease was 19 (range, 0-188) months. Complications occurred in 93 percent, including perineal abscess/fistula (63 percent), pouchitis (50 percent), and anal stricture (38 percent). Pouch failure (excision or current diversion) occurred in nine patients (29 percent) at a median of 66 (range, 6-187) months. Two of these 9 patients had preoperative anal disease (not significant). Comparing patients with failed pouches (n = 9) to patients with functioning pouches (n = 23), post-ileal pouch-anal anastomosis perineal abscess (67 vs. 26 percent, P = 0.05) and pouch fistula (89 vs. 30 percent, P = 0.01) were more commonly associated with pouch failure. Preoperative clinical, endoscopic, and pathologic features were not predictive of pouch failure or patient outcome. For those with a functional pouch, 50 percent have been or are currently on medication to treat active Crohn's disease. This group had six bowel movements in 24 (range, 3-10) hours, with leakage in 60 percent and pad usage in 45 percent.

Patients who undergo ileal pouch-anal anastomosis and are subsequently found to have Crohn's disease experience significant morbidity. Preoperative characteristics, including the presence of anal disease, were not predictive of subsequent pouch failure. We choose not to recommend the routine application of ileal pouch-anal anastomosis in any subset of patients with known Crohn's disease.

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. Complications may lead to failure, defined as removal of the reservoir with establishment of a permanent ileostomy or long-term diversion. Failure may be avoided for some patients by salvage surgery. The causes of failure are identified in this article and the procedures adopted to treat them are defined; a review of the literature was carried out to determine the effectiveness of the procedures.

Failure after restorative proctocolectomy results from complications, which may occur indefinitely during follow-up to a cumulative rate of about 15 per cent at 10-15 years. Sepsis accounts for over 50 per cent of these complications. Abdominal salvage procedures are successful in 20 to over 80 per cent of patients but the rate of salvage is dependent on the duration of follow-up, which might explain this variance. Local procedures are successful in 50-60 per cent of patients with pouch-vaginal fistula. Poor function accounts for about 30 per cent of failures. Abdominal salvage for outlet obstruction and low pouch capacitance results in satisfactory or acceptable function in up to 70 per cent of patients. There is no effective surgical salvage for pouchitis.

Salvage surgery must be discussed carefully with the patient, who should be made aware of the possible complications and the prospect of success, which is less than that in the general population of patients undergoing ileoanal pouch surgery.

The type of surgery performed for UC varies from patient to patient and must take into account the nutritional status and health of the patient, the presence of dysplasia or cancer, the desire of the patient to maintain continence, the preoperative anorectal function, the degree of confidence in the diagnosis of UC, and the technical constraint because of certain body habituses. A total proctocolectomy is the surgical procedure of choice for UC. A restorative proctocolectomy is the preferred surgical approach that not only cures the patient of the disease and prevents the development of colorectal cancer, but also maintains continence with an improved quality of life.

Inflammation of the ileoanal pouch (pouchitis) is one of the main complications after restorative proctocolectomy, yet its cause remains poorly understood. A standardized definition and diagnostic procedures in pouchitis are lacking.

We analyzed all cases of pouchitis occurring in a group of 308 patients (210 with ulcerative colitis, 98 with familial adenomatous polyposis) who took part in a prospective long-term follow-up program. The severity of pouchitis was measured using a pouchitis activity score (Heidelberg Pouchitis Activity Score). An algorithm for the classification and management of pouchitis was established which enables the clinician: 1) to determine the severity of pouchitis, 2) to differentiate between primary pouchitis and pouchitis caused by surgical complications (secondary pouchitis), and 3) to evaluate the course (acute vs. chronic (> 3 months)).

The median duration of follow-up was 48 (range, 13-119) months. At least one episode of pouchitis was diagnosed in 29 percent of patients with ulcerative colitis and in 2 percent of familial adenomatous polyposis patients. Secondary pouchitis occurred in 6 percent of ulcerative colitis patients and was cured by surgical treatment in 13 (87 percent) of 15 cases. Primary pouchitis was diagnosed in 23 percent of ulcerative colitis patients, including 6 percent of all ulcerative colitis patients with chronic primary pouchitis. The latter showed poor response to medical treatment. In one case multifocal high-grade dysplasia occurred. Histologic examination of the excised pouch identified a carcinoma originating from the ileal mucosa.

Ulcerative colitis patients after restorative proctocolectomy face a high risk of developing pouchitis. The algorithm used in this study was highly efficient in identifying patients with a secondary pouchitis who require surgical treatment and patients with chronic primary pouchitis. For the latter, long-term surveillance seems mandatory because of the risk of malignant transformation of the pouch mucosa.

The incidence and outcome of pelvic sepsis was analyzed in 210 patients who underwent restorative proctocolectomy for ulcerative colitis (UC) in 197 patients, and for familial adenomatous polyposis (FAP) in 13 patients. Pelvic sepsis developed in 18 patients (8.6%) and a significantly higher incidence was seen in men than in women, at 13.6% vs 3.7%, respectively (P < 0.05). The incidence of pelvic sepsis in patients with UC complicated by toxic megacolon and/or fulminant colitis was significantly higher that in those without any preoperative complications, at 36.4% vs 7.4% (P < 0.05). The incidence of pelvic sepsis following handsewn anastomosis was significantly higher than that following stapled anastomosis, at 15.6% vs 5.5% (P < 0.05). The outcome of pelvic sepsis in patients with a stapled anastomosis was better than that in those with a handsewn anastomosis. The prognosis of women who developed pelvic sepsis was better than that of men who developed pelvic sepsis. The risk factors predisposing to pelvic sepsis were UC, especially when complicated by toxic megacolon and/or fulminant colitis, and male sex, while a handsewn anastomosis was more vulnerable than a stapled anastomosis.

Pouchitis is the most frequent complication of ileal pouch-anal anastomosis for treatment of ulcerative colitis. There are several possible explanations. Among them, we focus on the one that considers pouchitis as an extracolonic manifestation of ulcerative colitis. The aim of this study was to investigate the association between pouchitis and extra-intestinal manifestations (EIM), which are frequent in these patients. Sixty patients underwent restorative proctocolectomy with an ileal J pouch (IPAA) from September 1984 to December 1998. Pouchitis was defined by clinical, endoscopic, and histologic criteria. The following extra-intestinal manifestations were studied: articular, cutaneous, hepatobiliary, ocular, genitourinary, and growth failure. Thirteen patients, of which 10 were female (76.9%), developed one or more episodes of pouchitis. Twelve patients of this group (92.3%) presented some kind of extra-intestinal manifestation, 4 pre-operatively (exclusively), 2 post-operatively (exclusively), and 6 both pre- and post-operatively (1.7 per patient). Twenty patients (42.7%) of the 47 without pouchitis did not present extra-intestinal manifestations; 10/35 (28. 5%) of females had pouchitis, compared to 3/35 (12.0%) of men. Pouchitis was more frequent among females, though not statistically significant. EIM increases the risk of pouchitis. Pouchitis is related to EIM in 92.3 % of cases, corroborating the hypothesis that it could be an extracolonic manifestation of ulcerative colitis.

To review the outcome after restorative proctocolectomy among children and adolescents with ulcerative colitis at a pediatric inflammatory bowel disease center.

The records of all patients with ulcerative colitis undergoing colectomy and ileoanal anastomosis at The Hospital for Sick Children, Toronto, Canada, were reviewed. Questionnaires concerning functional results were sent to patients with restored transanal defecation.

Seventy three patients (mean age, 13.2 years; range, 2.6-18.8 years) underwent ileoanal anastomosis (19 straight ileoanal anastomosis, 41 J pouch, 13 S pouch) between January 1980 and June 1995 and were observed 5.8+/-3.3 years. The ileoanal anastomosis is nonfunctional in 19 (26%) patients. Excision rates according to type of restorative procedure were J pouch, 7% (3 of 41); S pouch, 32% (4 of 13); and straight ileoanal anastomosis, 32% (6 of 19). Failure was usually attributable to intractable diarrhea among patients with straight ileoanal anastomosis but was caused by anastomotic leak or pelvic-perianal sepsis among patients with pouch procedures. Failure rates did not vary with age at ileoanal anastomosis. Among patients retaining ileoanal continuity, continence problems reported in the questionnaire were frequent and tended to be more extreme among younger patients. Overall, 90% of respondents reported satisfaction with the functional outcome of the restorative operation.

The success rate of the ileoanal anastomosis/J-pouch procedure is comparable to that in adult series. The ileoanal anastomosis/J-pouch procedure is the operation of choice for children and adolescents who want ileoanal continuity restored after colectomy for ulcerative colitis.

Our purpose was to determine the value of MRI in diagnosing pouch-related fistulas in patients with ulcerative colitis and to compare pulse sequences with and without contrast enhancement in their performance of visualization.

Forty-four patients with pelvic symptoms after restorative proctocolectomy underwent MRI. All 26 patients with pouch-related fistulas were treated surgically; 18 patients with pouchitis were treated conservatively. MRI was performed at 1.0 T with T1-weighted FLASH sequences before and after administration of Gd-DTPA, T2-weighted and proton density-weighted turbo SE sequences, and a T2-weighted fat saturation sequence. Images were analyzed for the presence of fistula; pulse sequences were additionally compared for best visualization on a four point scale of diagnostic confidence.

MRI detected 23 of 26 cases of fistulas; there were no false-positive diagnoses. Surgery revealed fistulas in three cases in which no pathology was found on MRI. Two patients had a short sinus tract at the pouch-anal anastomosis, and a third patient had a pouch-vaginal fistula. The Gd-enhanced FLASH sequence obtained the highest score, and second best was the T2-weighted fat saturation technique.

MRI is a valuable technique for diagnosing pouch-related fistulas, However, there are limitations in detection of short sinus tracts and pouch-vaginal fistulas. Highest diagnostic confidence is obtained with a Gd-enhanced FLASH sequence, which might be helpful after pelvic surgery or if the fact saturation technique is equivocal.

Pouchitis is a major long-term complication of the continent ileostomy as well as the ileoanal pouch anastomosis. When diagnosed on the basis of clinical, endoscopic and histologic features, this syndrome has been demonstrated almost exclusively in patients with ulcerative colitis. The clinical course, the endoscopic findings and the histologic abnormalities resemble those of ulcerative colitis. The association with extra-intestinal manifestations further supports the hypothesis that pouchitis represents ulcerative colitis in the small bowel. All ileal reservoirs show bacterial overgrowth, especially of anaerobes. As a response to this altered intraluminal environment chronic inflammation and incomplete colonic metaplasia occur. The efficiency of metronidazole does suggest that bacteriological factors play an important role in the pathogenesis of pouchitis.

Mucosal inflammation of the ileal pouch (pouchitis) is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Broad-spectrum antibiotics are the mainstay of treatment, however, 15% of patients with pouchitis have a chronic, treatment-resistant disease.

To determine the safety and efficacy of bismuth carbomer enemas in achieving and maintaining remission in treatment-resistant chronic pouchitis.

Twelve patients with treatment-resistant chronic pouchitis were treated nightly for 45 days with enemas containing elemental bismuth complexed with carbomer. Diagnosis of pouchitis and response to treatment were evaluated with the Pouchitis Disease Activity Index (PDAI), which includes clinical, sigmoidoscopic and histological criteria. Serum bismuth concentrations were determined by atomic absorption.

Ten of 12 patients (83%) went into remission, with a significant decrease of mean total PDAI score from 12 (range 9-15) to 6 (4-15) (P < 0.002), and were continued on bismuth carbomer enemas administered every third night for 12 months. Patients were monitored clinically, sigmoidoscopically and histologically every 2 months for evidence of recurrence (increase > or = 2 in the clinical symptom portion of the PDAI). Six of 10 patients (60%) were able to maintain remission throughout the 12-month trial; 4/10 had an exacerbation, two of which occurred soon after discontinuing daily treatment. Serum bismuth levels were negligible in all patients and no side-effects were registered.

Our findings suggest that bismuth carbomer enemas are safe and effective in achieving and maintaining remission in patients with treatment-resistant chronic pouchitis.

The aim of this article is to determine the outcome of the pelvic pouch after the occurrence of a fistula.

From 1983 to 1995, 1,040 pelvic pouch surgeries were done at our institution. We reviewed the records of all patients with pouch-related fistulas. Data were collected from chart reviews and our pouch registry.

Among 59 patients (22 males) with fistulas, mean age was 33 (range, 19-57) years. Preoperative diagnosis was mucosal ulcerative colitis (n = 52), indeterminate colitis (n = 6), and familial polyposis (n = 1). Site of fistulas included pouch/vaginal (n = 24), pouch/ cutaneous (n = 11), pouch/perineal (n = 16), and pouch/ presacral (n = 8). Postoperative diagnosis was mucosal ulcerative colitis (n = 40), Crohn's disease (n = 14), indeterminate colitis (n = 4), and familial polyposis (n = 1). One hundred eleven (range, 1-7) surgeries for treatment were performed. At a mean follow-up of 26 (range, 1-121) months, 19 pouches (32 percent) had been excised, 34 patients had functioning pouches and no fistula, 5 patients had a closed fistula but refused ileostomy closure, and 1-patient had died of unrelated causes (but the fistula was closed). Pouch type and preoperative diagnosis did not statistically affect pouch failure rates (P = 0.43 and 0.10. respectively).

Successful treatment of fistula from a pelvic pouch can be achieved in more than 60 percent of patients. However, multiple procedures may be needed for a successful outcome. Ultimately, 32 percent had their pouches excised.

The length of ileum used rather than pouch configuration per se is related to eventual functional outcome: A pouch constructed from 15- to 20-cm limbs is ideal. One-stage procedures appear feasible in those patients who are not malnourished or taking steroids and in whom a tension-free anastomosis may be achieved. Because most of our patients do not satisfy these criteria, single-stage IPAA is rarely used at the Mayo Clinic. The decision to excise the ATZ should relate to the risk of developing subsequent neoplasia. All patients with FAP should have a mucosectomy performed. Patients with CUC who do not have a mucosectomy should have life-long surveillance. Indeed, an argument can be made that all patients should undergo surveillance after IPAA. The decision to staple the anastomosis impacts little on eventual functional outcome but does preserve the ATZ with the attendant risk of recurrent disease, polyps, and neoplasia. When cancer is a presenting feature, the decision to perform IPAA should be based on the stage of the tumor and the subsequent need for radiation therapy. Patients with early-stage tumors not requiring adjuvant radiation therapy attain long-term function comparable to that of patients who have had an IPAA for benign disease.

Prognostic factors and outcome of pouch-related fistula were analysed from a series of 21 patients, 20 of whom had an ileal J pouch manually anastomosed to the dentate line following mucosectomy. Fistula occurred more often after pouch formation for ulcerative colitis than for familial adenomatous polyposis. In 6 patients the fistula occurred more than 5 months after closure of the diverting loop ileostomy. The origin of the leak was the anastomosis in 14 patients, the vertical staple line in two and the end of the efferent limb in five. Nine forms of treatment were utilized and these were successful in 11 patients and unsuccessful in ten including three pouch excisions. Adverse prognostic factors were late fistula, the presence of an enterocutaneous or a pouch-vaginal fistula track, and diagnosed or suspected Crohn's disease. Resolution of the fistula followed none of six diverting loop ileostomies performed alone, three of 33 attempted drainage procedures, four of ten direct closures, and four of five repeat ileal pouch-anal anastomoses. It is concluded that an aggressive therapeutic approach using repeat ileal pouch-anal anastomosis increases the success rate.

Primary sclerosing cholangitis (PSC), present in 5% of patients with ulcerative colitis, may be associated with pouchitis after ileal pouch-anal anastomosis. The cumulative frequency of pouchitis in patients with and without PSC who underwent ileal pouch-anal anastomosis for ulcerative colitis was determined. A total of 1097 patients who had an ileal pouch-anal anastomosis for ulcerative colitis, 54 with associated PSC, were studied. Pouchitis was defined by clinical criteria in all patients and by clinical, endoscopic, and histological criteria in 83% of PSC patients and 85% of their matched controls. PSC was defined by clinical, radiological, and pathological findings. One or more episodes of pouchitis occurred in 32% of patients without PSC and 63% of patients with PSC. The cumulative risk of pouchitis at one, two, five, and 10 years after ileal pouch-anal anastomosis was 15.5%, 22.5%, 36%, and 45.5% for the patients without PSC and 22%, 43%, 61%, and 79% for the patients with PSC. In the PSC group, the risk of pouchitis was not related to the severity of liver disease. In conclusion, the strong correlation between PSC and pouchitis suggest a common link in their pathogenesis.

Restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA) has become an established surgery for patients with chronic ulcerative colitis and familial adenomatous polyposis.

The authors report the results of an 11-year experience of restorative proctocolectomy and IPAA at a tertiary referral center.

Chart review was performed for 1005 patients undergoing IPAA from 1983 through 1993. Preoperative histopathologic diagnoses were ulcerative colitis (n = 858), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 75), and miscellaneous (n = 10). Information was obtained regarding patient demographics, type and duration of diseases, previous operations, and indications for surgery. Data were collected on surgical procedure and postoperative pathologic diagnosis. Early (within 30 days after surgery) and late complications were noted. Follow-up included an annual function and quality-of-life questionnaire, physical examination, and biopsies of the pouch and anal transitional zone.

Of the 1005 patients (455 women), postoperative histopathologic diagnoses were as follows: ulcerative colitis (n = 812), familial adenomatous polyposis (n = 62), indeterminate colitis (n = 54), Crohn's disease (n = 67), and miscellaneous (n = 10). During a mean follow-up time of 35 months (range 1-125 months), histopathologic diagnoses were changed for 25 patients. The overall mortality rate was 1% (n = 10 patients, early = 4, late = 6); one death (0.1%) was related to pouch necrosis and sepsis. The overall morbidity rate was 62.7% (1218 complications in 630 patients; early, n = 27.5%; late, n = 50.5%). Septic complication and reoperation rates were 6.8% and 24%, respectively. The ileal pouch was removed in 34 patients (3.4%), and it is nonfunctional in 11 (1%). Functional results and quality of life were good to excellent in 93% of the patients with complete data (n = 645) and are similar for patients with ulcerative colitis, familial adenomatous polyposis, indeterminate colitis, and Crohn's disease. Patients who underwent operations from 1983 through 1988 have similar functional results and quality of life compared with patients who underwent operations after 1988.

Restorative proctocolectomy with an IPAA is a safe procedure, with low mortality and major morbidity rates. Although total morbidity rate is appreciable, functional results generally are good and patient satisfaction is high.

A new method for allowing stool passage into the pelvic pouch before ileostomy closure to verify the defecation state and diminish stool frequency is reported herein. This was accomplished by fitting an ileostomy connector connecting the proximal and distal openings of the diverting loop stoma. The ileostomy connector was initially in place for 6 h a day, the length of time being gradually increased until it was able to be left in for 24 h a day over a 3-month period. The calculated daily frequency of stools decreased from 24 to 6 or 7 times, and the mean daily frequency immediately after ileostomy closure was 6.5 times. Physiological study also showed an improvement, with squeeze pressure increasing from 35 cmH2O to 116 cmH2O and the maximum tolerated volume increasing from 35 ml before, to 90 ml 3 months following the use of an ileostomy connector. Thus, we conclude that an ileostomy connector may be useful to predict postoperative functional outcome and its complications, and to diminish the frequency of defecation before ileostomy closure in patients with a covering loop stoma.

The techniques for ileoanal pull-through procedures have been well described previously. However, little attention has been given to the techniques to maximize ileal mesenteric length. Furthermore, no studies have provided data that support the technical recommendations. The purposes of this study are to describe our technique for ileal pouch construction and ileal mesenteric lengthening, and to provide data supporting our recommendations.

The operative summaries of 74 consecutive ileal J-pouch-anal anastomoses procedures were reviewed with attention to the management of the mesenteric vasculature.

Complete data with respect to the handling of the mesenteric circulation were available for 66 cases. Ileal J-pouch-anal anastomoses were achieved with both the ileal branch of the superior mesenteric artery and the ileocolic artery intact in 23% of cases. The ileocolic artery was divided in 48% of cases, and the ileal branch of the superior mesenteric artery was divided in 29% of cases. In addition, one or more distal arcade vessels between the vasa recta and the ileocolic artery were divided in 18% of cases. Ileal J-pouch-anal anastomosis was possible in all 74 patients.

These data emphasize the variability in mesenteric circulation and the complexity of pouch construction in patients undergoing ileoanal pull-through procedures. However, with attention to the techniques described, ileal J-pouch-anal anastomoses should be possible in virtually all patients.