Loop ileostomy: modification of technique.

INTRODUCTION: A loop ileostomy is a suitable procedure for faecal diversion. A number of technical improvements and advancement in stoma management have made its creation a suitable alternative to a loop colostomy. We describe an alternative technique for securing a loop ileostomy and perform a retrospective review of this technique. PATIENTS & METHOD: 40 patients who had a loop ileostomy performed as part of an abdominal procedure were reviewed. The loop of ileum was secured to the stoma site with a novel 'suture bridge' technique. RESULTS: 32 patients had the stoma formed to protect a distal anastomosis, 6 to palliate bowel obstruction, 1 to control faecal incontinence and another for colonic Crohn's disease. There were no incidences of paralytic ileus, mechanical obstruction, prolapse, retraction or bleeding after the loop ileostomies were formed. Thirty patients had their ileostomies closed. In 27 patients this was performed by excising the muco-cutaneous edge and anterior closure. Three patients had their stomas resected and an end-to-end bowel anastomoses. Following closure there were two complications in separate patients--self-limiting paralytic ileus and small bowel obstruction at the site of the stomal closure that required a second operation. There were no incidences of anastomotic leaks or bleeding in patients who had their ileostomy closed. No mortalities were attributed to either stoma formation or closure. CONCLUSION: We have described a safe alternative technique for securing a loop ileostomy with negligible complications in construction and closure as demonstrated in our results.

Prospective evaluation of ultrasound in distal ileal and colonic obstruction.

AIM: To evaluate prospectively the usefulness of ultrasound in determining the site and cause of distal small bowel and colonic obstruction. MATERIALS AND METHODS: Ultrasound findings in 60 consecutive patients with suspected distal ileal or colonic obstruction were correlated with final surgical and radiological diagnoses. The diagnostic value of ultrasound was compared with plain abdominal radiography (AXR) for the presence and level of obstruction. RESULTS: Forty-five patients were confirmed to be obstructed. Ultrasound correctly identified obstruction in 44/45 and the cause in 36/45 (80%). Overall sensitivity of US for obstruction was 98% and specificity 80%, compared with 79% and 53% respectively for the AXR. CONCLUSION: Ultrasound is useful in determining the presence and cause of distal ileal and colonic obstruction.

Colonic involvement in Fabry's disease.

The case of a 54 year old man with Fabry's disease and extensive jejunal and colonic diverticulosis causing colonic stricture is presented. Histological examination of the resected colon revealed evidence of ceramide trihexose deposition in the myenteric nerve plexus. Colonic involvement in Fabry's disease has not been reported before.

Reducing hours of work of preregistration house officers: report on a shift system.

OBJECTIVE: To determine the advantages and disadvantages of a shift system of working compared with the conventional on call system for preregistration house officers. DESIGN: A shift system of working was employed in the unit from 1 August 1989 to 31 July 1990. During attachments of three or six months four house officers rotated at intervals of one month among three daytime shifts and one night shift (Mondays to Fridays only). Weekends (48 hours) were worked on a one in three rota by the doctors working a day shift. The views of the house officers working this shift system were sought in writing and by direct interview. SETTING: Professorial surgical unit, Royal Liverpool Hospital. SUBJECTS: The 14 house officers who were attached to the unit for three or six months during their preregistration year. RESULTS: The shift system was preferred to conventional on call without exception. The incidence of chronic tiredness was reduced and formal hand-over between shifts resulted in more informed decision making by doctors while on call. During annual leave it was sometimes necessary to revert to the conventional one in three on call system to ensure that daytime work was completed. Other disadvantages were the long weekend shift and an inequitable distribution of the night shift. The house officers recommended extending the shifts to weekends and working the night shift one week in four. CONCLUSION: A shift system of working was effective in reducing chronic tiredness among house officers, who found it preferable to conventional on call arrangements. Shift working is feasible only if the daytime duties of the doctor working at night can be completed by the other doctors on the rota.

Changes in the absorption of bile acids after total colectomy in patients with an ileostomy or pouch-anal anastomosis.

Bile acid absorption was investigated using 75Se Taurohomocholate (SeHCAT) in controls and patients who had undergone total colectomy with either conventional ileostomy or pouch-anal anastomosis for ulcerative colitis or adenomatous polyposis. Whole-body retention of SeHCAT after 168 hours was greater in the controls than the patients who had undergone colectomy (P less than .05). Retention of SeHCAT did not differ significantly between patients with an ileostomy and patients with pouch-anal anastomosis, but patients with an ileostomy and ileal resection of more than 20 cm retained less SeHCAT than patients with a pouch-anal anastomosis (P less than .01). Analysis of fecal bile acids from ileostomies and pouches showed that bacterial metabolism of primary conjugated bile acids was greater in patients with a pouch. It was concluded that bile acid absorption was not significantly impaired by construction of a pouch compared with conventional ileostomy, but bacterial metabolism of bile acids was greater in the pouches.

Ileal ecology after pouch-anal anastomosis or ileostomy. A study of mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationship.

Ileal mucosal morphology, fecal bacteriology, fecal volatile fatty acids, and their interrelationships were studied in 15 patients with an ileal pouch-anal anastomosis and 14 patients with an ileostomy after proctocolectomy for ulcerative colitis. Pouch effluent, compared with ileostomy effluent, had a greater ratio of anaerobes to aerobes (p less than 0.05), and greater numbers of Bacteroides (p less than 0.01) and Bifidobacteria (p less than 0.05). Fecal volatile fatty acids, products of anaerobic bacterial fermentation, were also increased in pouch effluent compared with ileostomy effluent (propionate, p less than 0.05; butyrate, p less than 0.01). Mucosal change in the pouches showed no significant correlation with frequency of defecation, completeness of emptying, or pouch design, but the degree of villous atrophy was correlated with the number of Bacteroides (rs = 0.93, p less than 0.01) and with fecal butyrate (rs = 0.68, p less than 0.05). Fecal propionate was significantly correlated with the percentage of stool retained after defecation (rs = 0.82, p less than 0.01). These findings indicate that the bacterial ecology of ileal pouches has an important influence on the morphology of their mucosal lining.

Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis.

Mucosal proctectomy with endo-anal pull-through anastomosis (MP + PTA) for ulcerative colitis reduces resting anal pressure and low RAP has been found to correlate with minor leakage of faeces or mucus. Our hypothesis was that conservative proctocolectomy with an end-to-end ileo-anal anastomosis (EEA) would result in higher anal pressure and less leakage. Twelve patients were studied after EEA and 24 after MP + PTA: each was in good health several months after operation. After EEA, maximal RAP decreased from a median 90 cmH2O (60-116 cmH2O) to 70 cmH2O (25-104 cmH2O, P less than 0.01), whereas after MP + PTA maximal RAP decreased from 85 cmH2O (70-125 cmH2O) to 40 cmH2O (22-80 cmH2O, P less than 0.003). RAP after EEA was significantly greater than RAP after MP + PTA (P less than 0.001). The pressure profile of the anal sphincter in the EEA group did not differ significantly from that of the pre-operative group at any point from 6 to 1 cm from the anal verge, and the sphincteric high pressure zone averaged 4 cm in length both before and after operation. After MP + PTA, resting anal pressure at stations 1 to 4 cm from the anal verge was significantly less than pre-operative pressure (P less than 0.001) and the sphincteric high pressure zone was only 3 cm in length compared with 4 cm before operation. Anal squeeze pressures were similar in the two groups of patients. After EEA 11 of 12 patients achieved perfect continence, day and night, whereas after MP + PTA 58 per cent of patients experienced minor faecal leakage (P less than 0.01). These findings suggest that the entire anal canal should be kept intact in the course of conservative proctocolectomy for ulcerative colitis.

De-functioning stomas: a prospective controlled trial comparing loop ileostomy with loop transverse colostomy.

Patients undergoing colorectal surgery who required a defunctioning stoma were randomly allocated to receive either a loop ileostomy (n = 23) or transverse loop colostomy (n = 24). Assessment was made during construction, immediately postoperatively, during the period of outpatient supervision and before and after stoma closure. The ileostomy was associated with significantly less odour than the colostomy (P less than 0.01) and required significantly less appliance changes (P less than 0.05). Furthermore eleven patients (58 per cent) with a colostomy experienced three or more problems with stoma management compared with only three patients (18 per cent) with an ileostomy (P less than 0.05). Wound infection was also significantly more common after closure of the colostomy compared with the ileostomy. Both types of stoma were demonstrated objectively to defunction the distal bowel almost completely. These results indicate that a loop ileostomy is the procedure of first choice when a stoma is needed to defunction the distal colorectum.

Factors influencing bowel function after ileal pouch-anal anastomosis.

Seventeen patients were studied 3-31 months (median 6.4 months) after mucosal proctectomy and ileal pouch-anal anastomosis for ulcerative colitis (n = 15) or adenomatous polyposis (n = 2). Seven had a triplicated pouch, and ten a duplicated pouch. Clinical bowel function was determined by detailed questionnaire, and correlations sought between clinical end-points such as frequency of defaecation, urgency of defaecation and continence, and the results of laboratory investigations, comprising anal manometry, capacity and compliance of the pouch, completeness of emptying, faecal bacteriology and mucosal inflammation. Frequency of defaecation was found to be inversely correlated with both the capacity (rs = -0.66, P less than 0.01) and the compliance (rs = -0.53, P less than 0.05) of the pouch. Patients who could postpone defaecation for greater than 30 min had higher anal squeeze pressures (P less than 0.05) than patients who had greater urgency of defaecation. Patients with perfect anal continence had higher resting anal pressure (P less than 0.05) and emptied the pouch more completely (P less than 0.01) than patients who experienced minor leakage. The faecal flora of the pouches showed a greater predominance of anaerobes (P less than 0.01) and increased numbers of bacteroides (P less than 0.01) compared with the faecal flora of ileostomies, but the changes in the flora did not correlate with any aspect of bowel function. The best clinical results (i.e. perfect continence, low frequency of defaecation and little urgency) were associated with high anal pressure and with large volume, high compliance and complete emptying of the pouch. The completeness of emptying was similar for both designs of pouch, but the capacity and compliance of triplicated pouches were greater than the capacity and compliance of duplicated J pouches (P less than 0.05), and this was associated with a better clinical result in the triplicated pouches.

Comparison of the function of triplicated and duplicated pelvic ileal reservoirs after mucosal proctectomy and ileo-anal anastomosis for ulcerative colitis and adenomatous polyposis.

Among 39 consecutive patients who underwent colectomy, mucosal proctectomy and ileo-anal anastomosis, a triplicated pelvic ileal pouch was constructed in 17, and a duplicated pouch in 22 patients. There was no mortality, but complications such as anastomotic dehiscence and pelvic sepsis led to removal of the pouch in seven patients (18 per cent). The functioning of the pouch and anal sphincter was assessed in 31 patients 6 months, and in 22 patients 12 months after closure of the diverting ileostomy. By 6 months, all patients were either completely continent or experienced only minor leakage and defaecation could be deferred for more than 15 min by 81 per cent of patients and flatus distinguished from faeces by 90 per cent of patients. No significant differences between triplicated and duplicated pouches were discernible at 6 months. At 12 months defaecation was significantly less frequent (P less than 0.05) in patients with triplicated pouches (median, 5 times in 24 h) than in patients with duplicated pouches (7 times in 24 h). All patients with triplicated pouches and all except one with duplicated pouches were able to defaecate spontaneously, without needing to intubate the reservoir. Thus, provided the early postoperative problems can be overcome, most patients achieve good anal function after mucosal proctectomy combined with a pelvic ileal reservoir. No evidence was found in this study that the functional results of duplicated pouches were superior to those of triplicated pouches; in fact, the triplicated pouches proved to be slightly superior.

Pressure characteristics of the human ileocecal region--a key to its function.

Manometric recordings of the ileocecal region were made in 7 patients with a diverting loop ileostomy. An increase in the mean amplitude of phasic waves (10 +/- 3.2 cmH2O, p less than 0.01) associated with a smaller elevation of baseline pressure (6.4 +/- 1.2 cmH2O, p less than 0.01) was observed at the ileocecal junction in 81.5% of pull-throughs. Phasic activity was present at 63% of stations in the terminal ileum, but a discrete zone of persistent tonic activity was not observed. After colonic distention there was an increase in the amplitude (10 +/- 3.4 cmH2O, p less than 0.05) and duration of phasic activity (38% +/- 7%, p less than 0.01) in the junctional zone, as well as an increase in baseline pressure (4.8 +/- 1.3 cmH2O, p less than 0.05). Ileal distention produced a fall in junctional pressure. This study shows that the motility of the terminal ileum is characterized by a high incidence of phasic activity, which may be modulated by intraluminal distention. The findings suggest that flow across the ileocecal junction is regulated by modulation of phasic activity in the terminal ileum and not by a discrete zone of persistent tonic activity.

Doppler ultrasound in the diagnosis of vascular occlusion in renal transplantation..

In renal transplantation vascular occlusion is usually diagnosed too late for remedial surgery to be successful. A method of continuous monitoring of renal blood flow would provide evidence of a vascular problem and a chance of saving the graft. In this study directional Doppler ultrasound has been used to investigate arterial stenosis and venous outflow obstruction in a canine autograft model, using the pulsatility index (PI). The results demonstrate increasing PI with venous outflow block (P less than 0.005 at stenoses greater than 88% of venous diameter) and a fall in PI accompanying a progressive reduction in arterial inflow (P less than 0.001 at stenoses greater than 78% of arterial diameter). Identical results were achieved with both handheld and indwelling probes. The changes in the audible Doppler signal have a characteristic quality and the insertion of an indwelling Doppler probe offers a potential means of monitoring allograft blood flow in the immediate postoperative period and differentiating between venous and arterial obstruction.