• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of annsurgLink to Publisher's site
Ann Surg. Dec 1999; 230(6): 750.
PMCID: PMC1420938

Ileoneorectal Anastomosis

Early Clinical Results of a Restorative Procedure for Ulcerative Colitis and Familial Adenomatous Polyposis Without Formation of an Ileoanal Pouch

Abstract

Objective

To evaluate a new surgical procedure, ileoneorectal anastomosis (INRA), in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP).

Summary Background Data

Surgical treatment in UC and FAP aims to resect diseased colonic mucosa and restore oroanal continuity. The ileopouch anal anastomosis achieves this but has a 15% to 35% complication rate, a 10% failure rate, and an unpredictable functional outcome. An alternative surgical technique, INRA, has been developed in which the rectal mucosa is replaced by a vascularized ileal mucosa graft.

Methods

Eleven patients underwent an INRA procedure with a temporary diverting ileostomy. Clinical history, repeat endoscopy, histologic examination, and rectal compliance measurements were carried out before and after surgery.

Results

The INRA procedure was technically successful in all patients. Endoscopy showed ingrowth of ileal mucosa in the neorectum, with 100% coverage after 6 weeks. No patient had pelvic sepsis, neorectal–anal or –vaginal fistula, autonomic nerve damage, or fecal incontinence. Neorectal function improved with time. The median 24-hour defecation frequency decreased from 15 (range 9 to 25) to 7 (range 4 to 10) at 11 months follow-up, and the median maximum tolerated volume increased to 157 (range 130 to 225) ml. Anal manometry and electrosensitivity were not affected by the surgery. Histologic biopsy samples after 1 year showed a normal small intestinal mucous membrane, without inflammation or fibrosis.

Conclusion

The combination of a low complication rate and good neorectal function at 1 year is a substantial improvement that justifies extension of the clinical application in patients with UC and FAP.

Since its introduction by Parks in 1978 and after several modifications, the ileopouch anal anastomosis (IPAA) has become the restorative procedure of choice after proctocolectomy in the surgical treatment of ulcerative colitis (UC) and familial adenomatous polyposis (FAP). 1 The results of IPAA are generally appreciated by patients, although the procedure is associated with a relatively high complication rate of 15% to 35% and a failure rate of approximately 10%. 2–4 The most serious complications are pelvic sepsis, pouch–anal and –vaginal fistulas, strictures of the ileoanal anastomosis, fecal incontinence due to sphincter damage, and sexual and bladder dysfunction due to autonomic nerve destruction. The rectal excision and the ileoanal anastomosis are the two critical phases of the surgical procedure that lead to the majority of the complications. Modifications in the surgical technique during the last decade have not resulted in a substantial decrease in the rate of these complications. 5–12 Level of continence, stool frequency, and ability to evacuate are still unpredictable. Such high complication and failure rates dictate a continuing search for ways to improve the outcome of surgical treatment of UC and FAP. 13

Because the IPAA technique has reached the stage where no further improvements are to be expected, we worked on a completely different concept based on the knowledge that both UC and FAP are mucosal diseases. Removal of the rectal muscle wall is, in fact, unnecessary. This led to a surgical technique that is intended to remove all of the diseased tissue (i.e., the colorectal mucosa), restore oroanal continuity, preserve reservoir and evacuation capacity similar to that of the rectum, and reduce the postoperative complication and failure rates. The ileoneorectal anastomosis (INRA) is a new procedure in which, after a subtotal colectomy, the rectal wall is preserved and the rectal mucosa replaced by transposition of ileal mucosa. No rectal dissection needs to be carried out, and a safe ileorectal anastomosis can be performed. The feasibility of the surgical technique and the survival and ingrowth of the neorectal mucosa (Fig. 1) with subsequent formation of a compliant neorectum have been proven (Fig. 2) in a study using pigs; detailed results of this experimental work will be reported elsewhere.

figure 3FF1
Figure 1. Histologic examination of the neorectal resection specimen of a pig, showing a composite bowel wall with (1) perirectal fatty tissue, (2) muscularis propria of the rectum, (3) small intestinal submucosa and mucosa (hematoxylin and eosin stain). ...
figure 3FF2
Figure 2. Excision specimen 1 year after an INRA procedure in a pig, showing a normal ileorectal anastomosis with a compliant neorectum.

This paper presents the early clinical results with INRA in humans, carried out after approval by the medical ethics committee based on the favorable results of the earlier experimental work.

PATIENTS AND METHODS

Surgical Technique

The procedure was developed to include the following characteristics: removal of all (potentially) diseased tissue, avoidance of intrapelvic, extraperitoneal dissection, preservation of the complete rectum (minus mucosa) with an intact vascular and nerve supply, coverage of the denuded rectal wall with mucosa of “noncolonic” origin, and restoration of oroanal continuity.

The patient is placed in the lithotomy position to allow a combined abdominal and perineal approach. The actual procedure is performed through a midline incision and started by removal of the entire colon up to, but not beyond, the peritoneal reflection at the pelvic rim. No extraluminal intrapelvic dissection is carried out. The procedure is continued inside the remaining rectum after insertion of six to eight stay sutures for optimal exposure of the lumen.

Subsequently, the mucosectomy is started (Fig. 3).For the abdominal part, a dissection plane is developed immediately below the muscularis mucosae in the submucosal layer. Every effort is made to preserve the muscle layers of the rectum. The dissection is carried out circumferentially and then stepwise distally. Careful hemostasis during this part of the procedure by electrocoagulating numerous small vessels between the mucosa and the muscle wall is essential for removal of all the rectal mucosa, but at the same time the integrity of the remaining rectal wall must be maintained.

figure 3FF3
Figure 3. Rectal mucosectomy, surgical technique. Dentate line (1), circular and longitudinal rectal muscle layers (2), rectal mucosa (3).

The most distal 2 to 5 cm of the mucosectomy is performed using a perineal approach. The anus is flattened out by four to six stay sutures, and the mucosa is lifted by submucosal injection of a diluted (1:100,000) epinephrine solution. The rectal mucosectomy specimens are examined histologically in detail for completeness of dissection (Fig. 4).

figure 3FF4
Figure 4. Histology of rectal mucosectomy specimens. (A) A patient with UC. The dissection plane is invariably located beneath the submucosa, which is thickened, whereas the mucosa has been destroyed by the long-lasting colitis (hematoxylin & ...

The next step is to create a vascularized mucosal sling from the terminal ileum (Fig. 5). 14 To facilitate this part of the procedure, an appropriately sized mold is inserted into the terminal ileum. Subsequently, the serosa and the muscular layers of the distal 20 cm of the terminal ileum are stripped. Only a small band of the seromuscular coat along the mucosal sling is left intact at the mesenteric side to preserve the vascular supply of the mucosal sling.

figure 3FF5
Figure 5. Ileal mucosal sling formation, surgical technique. Ileal mucosa (1), vessels penetrating ileal wall (2), meshlike graft incisions (3).

Also, at the distal end of the sling, a 1-cm ring of complete nonstripped ileum is left to facilitate the transposition of the mucosal sling into the rectum and up to the anus, and to create the mucosoanal anastomosis.

Using the intraluminal mold as an anvil, multiple longitudinal incisions between the vascular ramifications are made in the mucosal sling to increase the diameter for better adaptation to the rectum. This also helps to prevent accumulation of fluid and blood between the cuff of rectal muscle and the transposed mucosa.

To accommodate the mesentery of the vascularized mucosal sling, an incision approximately 5 cm long is made at the right lateral side of the rectal cylinder. The meshed mucosal sling is subsequently introduced into the denuded rectum. This maneuver is substantially facilitated by first introducing a circular laparoscopy bag (Transducer Cover, Int. Medical Products BV, Zutphen, The Netherlands) transanally. The distal end of the mucosal sling is then fixed to the nonkeratinizing squamous epithelium of the dentate line with 8 to 10 absorbable 3-0 monofilament sutures (Monocryl Ethicon, Johnson & Johnson Int., Brussels, Belgium), creating a mucosoanal anastomosis. A tight-fitting pack with 0.1% iodine is then introduced through the anus and mold into the sling, thus pressing the meshed mucosal sling against the rectal wall.

Subsequently, an anastomosis is made between the distal intact part of the ileum, immediately proximal to the mucosal sling, and the proximal part of the rectum using a continuous, one-layer, 3-0 absorbable monofilament suture (PDS Ethicon, Johnson & Johnson), creating the ileorectal anastomosis of the INRA procedure (Fig. 6). The procedure is finished by fashioning a temporary diverting ileostomy.

figure 3FF6
Figure 6. The ileoneorectal anastomosis: anastomosis (3) between the ileum and proximal rectal muscular wall with the ileal mucosa sling (2) plugged on the denuded rectal muscle. The distal end is sutured to the dentate line (1). The central vascular ...

Preoperative Management

All patients had given their written informed consent. Bowel preparation (Klaen-prep, Norgine BV, Utrecht, The Netherlands) on the day before surgery was carried out only in patients without a previous subtotal colectomy. Antibiotic prophylaxis, immediately before surgery, consisted of amoxicillin plus clavulanic acid (2000/200 mg, intravenously), which was repeated 2 hours later (1000/200 mg, intravenously).

Postoperative Management

The intraluminal pack was removed on the second postoperative day and a catheter was inserted for irrigation and drainage of the neorectal lumen. After 1 week, rectoscopy was performed to evaluate the viability of the neorectal mucosa.

Follow-Up

Patients were seen in the outpatient clinic at 3 and 6 weeks after surgery and at 3-month intervals thereafter. At every visit a standardized history was taken, with emphasis on defecation frequency, level of continence, urgency, and stool consistency. Physical examination was performed, including inspection of the anus and digital rectal examination. Closure of the ileostomy was planned for approximately 3 months after the INRA procedure.

Functional Evaluation

Evaluation of anorectal function included measurement of the maximum tolerated volume (by barostat, Distender series II, G&J Electronic Inc., Ontario, Canada). Anal manometry and electrosensitivity (four-channel water perfusion manometry, MMS, Enschede, The Netherlands) measurements were obtained to assess function over time. Studies were performed before surgery and at regular intervals afterward.

Endoscopy

Endoscopy was repeated at 6 weeks and 3, 6, and 12 months to evaluate the vitality and inflammatory activity of the mucosa, to estimate the surface covering with mucosa, and to take multiple biopsies.

Pathology

The rectal mucosectomy specimens and ileal serosa-muscle strips were processed for histopathology to examine the dissection planes and look for completeness of mucosectomy. Biopsies of the mucosa, taken at endoscopy, were processed for detailed routine histopathologic evaluation (hematoxylin and eosin staining) and connective tissue staining (Elastica, von Giesson).

RESULTS

The INRA procedure was performed in six men and five women, nine with UC and two with FAP. All of the patients with UC previously had a subtotal colectomy with end-ileostomy (eight) or ileorectal anastomosis (one). Neither patient with FAP had undergone surgery. The median age was 36 years (range 20 to 56).

Surgical Data

The procedure was technically successful in all patients. Conversion to a conventional pouch was not necessary. The median surgical time was 360 minutes (range 270 to 540). The median blood loss was 2200 ml (range 500 to 4000). In the last three patients, the surgical time was reduced to 4.5 hours and the blood loss to 500 ml. The median interval to closure of the ileostomy, carried out so far in nine patients, was 93 days (range 61 to 111).

Follow-Up

The median postoperative follow-up period was 11 months (range 4 to 16). No signs of specific INRA-related complications were encountered during follow-up. There were no cases of anastomotic leakage, pelvic sepsis, neorectal–anal or –vaginal fistula, or fecal incontinence. No instances of bladder or sexual dysfunction were reported, so it appears that no neurologic damage had been inflicted.

Six patients had complications. Three patients had small bowel obstruction, for which conservative treatment (one) or surgical treatment (two) was necessary. Two patients had stoma-related complications: one had a parastomal fistula and one a parastomal abscess. In one patient, who had a history of a right-sided lower leg thrombosis, an ipsilateral compartment syndrome developed during the INRA procedure; this patient subsequently needed a fasciotomy. Six patients had mucosoanal stenoses, which were dilated with repeated self-administered Hegar dilators.

Symptomatic Results

Passive and urge fecal incontinence was not reported. Six of nine patients (with closed ileostomies) were able to defer from defecation for >2 hours, whereas three patients, with short follow-up, were able to defer from defecation up to 1 hour. Some patients had difficulty in discriminating gas from fluid or solid early after closure of the ileostomy. Nocturnal soiling occurred occasionally in three patients. This disappeared by 3 months after closure of the ileostomy. The recorded 24-hour defecation frequency was high early after closure of the ileostomy, with a median of 15 (range 9 to 25) (Fig. 7). After 1 year, the frequency had decreased in all to a median of 7 (range 4 to 10).

figure 3FF7
Figure 7. Defecation frequency of INRA patients over time.

Functional Outcome

Concordant with the improvement in defecation frequency and continence, the maximum tolerated volume of the neorectum showed an increase over time to a median of 157 ml (range 130 to 225) 1 year after surgery (Fig. 8). The variation in the preoperative volumes is explained by the fact that at the time of the INRA procedure, some of the rectums were diverted but others were not. Anal manometry and electrosensitivity tests did not show a significant difference between preoperative and postoperative values (Table 1).

figure 3FF8
Figure 8. Maximum tolerated volume of the neorectum and its development over time after the INRA procedure.
Table thumbnail
Table 1. PRE- AND POSTOPERATIVE MANOMETRIC AND ELECTROSENSITIVITY RESULTS

Endoscopy

Endoscopy revealed survival of the mucous membrane 1 week after surgery in all patients. Estimation of the neorectal surface, covered by small intestinal mucosa, showed ingrowth varying from 50% to 100% after 1 week, increasing to complete coverage in all patients after 6 months.

Pathology

Microscopic examination of the rectal mucosectomy specimens showed that the dissection plane was invariably located below the submucosa, indicating a complete mucosectomy (see Fig. 4). During the first 3 months after surgery, no histologic biopsies were performed. However, the histologic pattern of survival of the mucous membrane has been documented in the experimental study on pigs. In that study, serial biopsy samples of the neorectal mucous membrane showed in the first 2 weeks a “normal” small intestine mucosa with a dense mixed inflammatory infiltrate and ulcerations up to the submucosal layer. Subsequently, partial to subtotal villous atrophy developed, with disappearance of the goblet cells and brush border. Nevertheless, regeneration of the villous architecture is completely possible from the undamaged proliferative compartment of basal cells deep in the crypts. Normal length and structure of the villi lined by enterocytes, goblet cells, and brush border were seen in the neorectal biopsy samples of the pigs after 3 months. In this period, the diverting ileostomy was removed and oroanal continuity was restored in all subjects. After this, multiple neorectal biopsy samples were taken at repeated intervals.

The histologic findings in humans were comparable to the pattern seen in the pig study (Fig. 9). Three months after the INRA procedure, the villi were slightly shortened, but an intact lining with goblet cells, enterocytes, and brush border was present. The dense inflammatory infiltrate, together with the intraepithelial lymphocytes, had disappeared. For months, there was an irregular but persistent population of lymphocytes and plasma cells in the lamina propria, combined with lymphedema. Submucosal inflammation was not detected. After 6 to 12 months, the villi were of normal length and the mucosa was completely normal, without significant inflammatory cells. The histologic picture did not differ from normal intestinal mucosa and is comparable to that of pouch mucosa. Between 6 and 12 months, three patients showed the histologic hallmarks of pouchitis (intraepithelial inflammatory cells) in the neorectal mucosa. After medical treatment with antibiotics, the neorectal mucous membrane recovered completely.

figure 3FF9
Figure 9. Histology of the neorectal mucosa during follow-up after the INRA procedure. (1) At 1 week: normal length of the villi with a dense mixed inflammatory infiltrate and ulcerations. (2) At 6 weeks: subtotal villous atrophy with disappearance of ...

DISCUSSION

This study showed that the INRA procedure is technically feasible, and continuation on a broader scale is justified. No specific INRA-related complications were encountered. All requirements to compete with IPAA were essentially fulfilled because the three stipulations for alternative restorative surgery were met. Histologic evaluation of the rectal mucosectomy specimens showed that the dissection plane was invariably located at the intersection between the submucosa and the rectal muscle layer. The removal of the diseased mucosa was conducted in continuity and was complete in all cases. Oroanal continuity was restored, with preservation of a functional neorectal reservoir. Repeated endoscopy and histologic biopsy samples revealed complete ingrowth of the ileal mucosa in all patients. The median 24-hour defecation frequency was 7 (range 4 to 10) at approximately 1 year, without fecal incontinence. The median maximum tolerated volume of the neorectum was 157 ml (range 130 to 225). These data are in concordance with the improvement of symptomatic outcome and general health of the patients.

The concept of replacement of the rectal mucosa is not new; several experimental studies have been published. In the treatment of UC and FAP, several preliminary studies have been reported on rectal mucosa replacement, but only Peck developed this technique into clinical application. 15 In his concept, ileal mucosa was transposed to the denuded rectum, with end-ileostomy formation (stage I). In a second procedure after 6 months (stage II), a side-to-side ileorectal anastomosis was made. This approach led to a functioning reservoir in 23/29 patients with a median 24-hour defecation frequency of 6. The complexity of the two-stage procedure and the limited vascular supply to the isolated ileal mucosal segment were probably responsible for the failure in six patients and may have contributed to the discontinuation of this technique. Moreover, after 1978, the increased popularity of IPAA also may have further limited the application of this concept. 1

Twenty years after the development of the IPAA in 1978, the complication and failure rates are persistently high. During the first 10 years after it was introduced, a gradual improvement was experienced, probably due to a learning curve effect and evolution of the technique. However, the results have since stabilized. Recent large series do not show important differences in the rates of complications or failure: pelvic sepsis (4% to 17%), stricture at the ileoanal anastomosis (3% to 16%), pouch–anal or –vaginal fistula (1% to 9%), autonomic nerve damage with sexual dysfunction (0% to 3%), intestinal obstruction (6% to 25%), and pouch failure with deviation or excision (3% to 11%). 2–8 It is surprising that the high complication ratios also occur in renowned institutes with extensive experience in this field of surgery:

  • • Pelvic sepsis: Cohen et al, 7 17%, n = 483 patients; Fazio et al, 2, 15%, n = 1005
  • • Pouch–anal or –vaginal fistula: Meagher et al, 4 9.4%, n = 1310
  • • Stricture of the ileoanal anastomosis: Fonkalsrud, 16 16%, n = 145; Fazio et al, 2 14%, n = 1005
  • • Autonomic nerve damage: Fazio et al, 2 3%, n = 1005
  • • Intestinal obstruction: Fazio et al, 2 25%, n = 1005; Nicholls, 5 13%, n = 150
  • • Pouch failure: Meagher et al, 4 10%, n = 1310; Sagar et al, 17), 11%, n = 206.

The INRA procedure can be expected to give better results than IPAA because there is no rectal dissection and no anastomosis in the pelvis. The ileorectal anastomosis is above the pelvic inlet: the perirectal tissue, with its vascularization and innervation, is not affected. Pelvic sepsis will not occur. Iatrogenic bladder and sexual dysfunction caused by denervation is, in principle, excluded. Strictures, as seen with the ileoanal anastomosis, are less likely to occur as the ileal mucosa grows into the well-vascularized rectal muscular wall. Such strictures are more difficult to treat than the mild, temporary stenoses seen in some INRA patients. These stenoses were easily treated by self-administered dilatation, with full recovery. INRA would not be expected to change the percentage of intestinal obstructions, a complication related to laparotomy.

In INRA patients after closure of the ileostomy, the initial defecation frequency was high. The maximum tolerated volume was relatively low for approximately the first 6 months, contributing to the high frequency. Apparently the new rectum does not function as a reservoir from the start. The reduced capacity may result from initial shrinkage of the rectal wall due to incomplete coverage of the muscle layer by the transposed ileal mucosa, and from the inflammatory infiltrate observed in that mucosa. Complete mucosal coverage and the disappearance of this infiltrate without formation of fibrosis lead to a gradual increase in capacity and to gradual functional improvement. The median 24-hour defecation frequency in this study of 7 (range 4 to 10) is comparable to the frequency of 6 reported by both Fazio et al 2 and Meagher et al 4 in large series. The duration of follow-up in this study was shorter (11 months vs. 3.5 and 10 years, respectively), and the frequency is still decreasing. All patients in this study have full passive and urge fecal continence and the ability to defer defecation. Incontinence in pouch patients, however, is reported at 2% to 7% in recent series from expert centers (Meagher et al, 4 7%, n = 1310). Although the risk of incontinence cannot be excluded in the INRA procedure because of the transanal manipulation needed to perform the mucosectomy, iatrogenic sphincter damage is less likely than with ileoanal anastomosis.

These pilot study results in humans are promising, but two caveats must be noted. The surgical procedure remains difficult and time-consuming, and the blood loss was high in early cases. These are most likely to be learning curve effects, and both have been reduced considerably during the course of the pilot study. The other potential drawback is that rectomucosectomy must be performed scrupulously. In the early days of the pouch procedures, when rectomucosectomy was a standard part of the procedure, the development of carcinoma in the rectal cuff was reported. We emphasized the completeness of the mucosa/submucosa cylinder and believe that complete mucosectomy is possible. Cuff abscesses, as reported in the early stage of IPAA, were not observed in our pilot experiment. Retention of mucus and blood in the cuff between the pouch and the rectal muscle is prevented in the INRA procedure by irrigating the ileal mucosal sling. Further, changes in the technique, such as different mucosectomy techniques, simultaneous rectomucosectomy and ileal mucosal sling formation, or INRA procedures without diverting ileostomies, might further reduce surgical time and blood loss as well as the complexity of the procedure.

We conclude that INRA has already shown, despite its limited clinical application, several important advantages over IPAA. Further development of the INRA procedure seems justified. If the satisfying results and low complication and failure rates are maintained on a larger scale, a substantial improvement will be achieved for patients with UC and FAP, and appropriate modifications in the technique can be achieved.

Acknowledgment

Surgical illustrations were drawn by Dr. W. Renooij.

Discussion

PROF. F. HARDER (Basel, Switzerland): This is a very ingenious model to replace the diseased rectal mucosa with healthy vascularized autologous mucosa within the muscular tube with, hopefully, preserved reservoir function. The aim is to maintain a good, compliant, innervated reservoir with an intact sphincter mechanism and lined with healthy small bowel mucosa. In fact, in 1980, Donald Peck published in Annals of Surgery a series of more than 20 patients in whom the rectal mucosa was replaced with a pedicled ileal mucosa tube. Due to inadequate tissue perfusion in the distal part this became fibrotic. The technique was changed to full-thickness ileal transplantation in two stages. In the second stage the anterior rectum was split, and the ileum was anastomosed as a wide patch onto the split and already grafted rectum. The results reported were good to excellent. Why was it abandoned? What in your technique is the optimal length of the preserved rectum? In order to facilitate complete and safe mucosectomy in ulcerative colitis, a somewhat shortened rectum that also would be easier to be grafted could do the job. Tissue engineering is becoming an important research tool and has been successful in covering mucosal surfaces, for example, to replace buccal mucosa in man using autologous cells cultured in vitro. Could you speculate on future application of a mucosal layer grown in vitro to cover at least part of the rectum after mucosectomy? And a technical question: How do you make sure that the transplanted, meshed mucosal tube is maintained in position, in good contact with the rectal muscle wall? Do you introduce for some time a soft sponge, a kind of a stent? Again, I congratulate you on this beautiful and successful application of experimental animal work in man.

DR. C. VAN LAARHOVEN (Closing Discussion): Two reasons seem responsible for the abandonment of the Peck operation. The limited vascular supply of the transposed ileal mucosa sling failed to give a patent neorectal lumen in some cases, and impaired the compliance of the neorectum as a reservoir. Together with the development of the ileopouch anal anastomosis, this may have led to a loss of interest in the technique of mucosa transposition.

As to your question about the optimal length of the preserved rectum, I have the following answer. The starting point of the mucosectomy and for the ileorectal anastomosis is chosen well above the peritoneal reflection layer. Firstly, preservation of the whole is pursued from a functional point of view. Secondly, the rectosigmoid muscle wall, lined by the peritoneal serosa, is strong, which makes the ileorectal anastomosis more reliable.

You argued that, in order to facilitate complete and safe mucosectomy in ulcerative colitis, a somewhat shortened rectum could do the job, and also would be easier to be grafted. However, completeness of mucosectomy is determined by dissection in the right plane, i.e. between the submucosa and circular muscle layer of the rectum. Completeness of mucosectomy does not depend on the length of dissection. Preparation of a (long) ileal mucosa sling is not a problem, nor is its transposition and grafting to the rectal wall surface.

In vitro cultured squamous autologous mucosa epithelium has indeed come into clinical application, in orofacial surgery, for instance, to cover mucosal defects of the palate. In vitro culturing of small bowel mucosa cells is more difficult due to the differences in epithelial covering qualities of these cells, and due to the difficulty of culturing small bowel mucosa cells in a sterile environment. Campbell et al showed in an animal experimental study that small bowel mucosa cells seeded in a denuded rectum did show survival and ingrowth of the cells, but failed to give a compliant neorectal reservoir. Considering these difficulties, it seems that the transplantation of cultured small bowel mucous membrane, although an attractive concept, still has many obstacles to overcome.

To answer your last question: after transposition of the mucosa on the denuded rectal wall, a gynecological pack is inserted and left for 2 days. After removal of the pack, a catheter is inserted for daily irrigation and drainage of the neorectal lumen for 1 week. Like in split skin grafts, the mucosal epithelium and rectal muscle are structures who naturally “belong” to each other. The epithelium needs a subsoil—muscle, fascia, etc.—and the muscle needs a cover—skin, mucous membrane, etc. Therefore, 2 days after removal of the pack, the mucous membrane appears to be fixed to the muscle wall, and no further immobilization is necessary.

Footnotes

Correspondence: Cees JHM van Laarhoven, MD, PhD, Dept. of Surgery, University Hospital Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.

Presented at the Sixth Annual Meeting of the European Surgical Association, at the Royal College of Surgeons of England, London, United Kingdom, April 23–24, 1999.

Supported by the K.F. Hein Fund.

Accepted for publication July 1999.

References

1. Parks AG, Nicholls RJ. Proctocolectomy without ileostomy for ulcerative colitis. Br Med J 1978; 2: 85–88. [PMC free article] [PubMed]
2. Fazio VW, Ziv Y, Church J, et al. Ileal pouch-anal anastomoses: complications and function in 1005 patients. Ann Surg 1995; 222: 120–127. [PMC free article] [PubMed]
3. Wexner SD, Wong WD, Rothenberger DA, Goldberg SM. The ileo-anal reservoir. Am J Surg 1990; 159: 178–185. [PubMed]
4. Meagher AP, Farouk R, Dozois RR, et al. Ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 1998; 85: 800–803. [PubMed]
5. Nicholls RJ. Restorative proctocolectomy with various types of reservoir. World J Surg 1987; 11: 751–762. [PubMed]
6. Keighley MRB, Yoshioka K, Kmiot W. Prospective randomized trial to compare the stapled double lumen pouch and the sutured quadruple pouch for restorative proctocolectomy. Br J Surg 1988; 75: 1008–1011. [PubMed]
7. Cohen Z, McLeod RS, Stephen W, et al. Continuing evolution of the pelvic pouch procedure. Ann Surg 1992; 216: 506–512. [PMC free article] [PubMed]
8. Lewis WG, Miller AS, Williamson MER, et al. The perfect pouch: what makes the difference. Gut 1995; 37: 552–556. [PMC free article] [PubMed]
9. McIntyre PB, Pemberton JH, Beart RW, et al. Double-stapled versus handsewn ileal pouch-anal anastomosis in patients with chronic ulcerative colitis. Dis Col Rect 1994; 37: 430–433. [PubMed]
10. Johnston D, Williamson MER, Lewis WG, et al. Prospective controlled trial of duplicated (J) versus quadruplicated (W) pelvic ileal reservoirs in restorative proctocolectomy for ulcerative colitis. Gut 1996; 39: 242–247. [PMC free article] [PubMed]
11. Järvinen HJ, Luukkonen P. Comparison of restorative proctocolectomy with and without covering ileostomy in ulcerative colitis. Br J Surg 1991; 78: 199–201. [PubMed]
12. Grobler SP, Hosie KB, Keighley MRB. Randomized trial of loop ileostomy in restorative proctocolectomy. Br J Surg 1992; 79: 903–906. [PubMed]
13. Laarhoven v CJHM, Schipper MEI, Vroonhoven v ThJMV, Gooszen HG. Operatieve behandeling van Colitis Ulcerosa en Familiaire Adenomateuze Polyposis, de evolutie gaat door. Ned Tijdschr Geneesk 1999; 143: 662–626. [PubMed]
14. Montagne GJ. Longitudinal myectomy of ileum for bladder substitution: an experimental study. Thesis, Rodopi, Amsterdam, 1993.
15. Peck DA. Rectal mucosal replacement. Ann Surg 1980; 191: 294–303. [PMC free article] [PubMed]
16. Fonkalsrud EW. Update on clinical experience with different surgical techniques of endorectal pull-through operation for colitis and polyposis. Surg Gynecol Obstet 1987; 165: 309–316. [PubMed]
17. Sagar PM, Lewis W, Holdworth PJ, Johnston D. One-stage restorative proctocolectomy without temporary defunctioning ileostomy. Dis Col Rect 1992; 35: 582–858. [PubMed]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins
PubReader format: click here to try

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

  • Cited in Books
    Cited in Books
    PubMed Central articles cited in books
  • MedGen
    MedGen
    Related information in MedGen
  • PubMed
    PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...